1
|
Terashima S, Yamaguchi M, Ishihara T, Hagita J, Katsuno T, Ito M, Sugiyama H, Iwagaitsu S, Nobata H, Kinashi H, Ishimoto T, Banno S, Ito Y. Mepolizumab administration for eosinophilic granulomatosis with polyangiitis in an elderly patient with an abrupt onset of limb ischaemia and peripheral neuropathy: A case-based literature review. Mod Rheumatol Case Rep 2023; 7:142-147. [PMID: 36107735 DOI: 10.1093/mrcr/rxac073] [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: 03/04/2022] [Revised: 04/11/2022] [Accepted: 05/21/2022] [Indexed: 01/07/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a type of anti-neutrophil cytoplasmic antibody-associated vasculitis characterised by small- to medium-sized vessel vasculitis and is typically associated with eosinophilic granulomatous inflammation. EGPA can affect any organ system, most commonly the lungs, skin, and the nervous system. However, limb ulcers are rare complications and have only been described in few case reports. Furthermore, no documented cases of EGPA have been treated with mepolizumab. Herein, we report a case of an 86-year-old Japanese woman with anti-neutrophil cytoplasmic antibody-negative EGPA, who had an abrupt onset of upper limb ulcers and bilateral foot drop due to multiple mononeuropathy. Clinicopathological sural nerve biopsy showed eosinophil-associated vascular damage. The patient was administered steroids, intravenous immunoglobulin, vasodilators, and mepolizumab; this resulted in clinical improvement of her finger ulcers and peripheral neuropathy without any adverse effects. In cases of an abrupt onset of limb ischaemia and peripheral neuropathy, physicians should consider the possibility of EGPA as a differential diagnosis. Furthermore, the early administration of mepolizumab might yield better outcomes in terms of improving limb ischaemia and peripheral neuropathy.
Collapse
Affiliation(s)
- Seika Terashima
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Tomomi Ishihara
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Junichiro Hagita
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Mayumi Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hirokazu Sugiyama
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| |
Collapse
|
2
|
Amouei M, Momtazmanesh S, Kavosi H, Davarpanah AH, Shirkhoda A, Radmard AR. Imaging of intestinal vasculitis focusing on MR and CT enterography: a two-way street between radiologic findings and clinical data. Insights Imaging 2022; 13:143. [PMID: 36057741 PMCID: PMC9440973 DOI: 10.1186/s13244-022-01284-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/04/2022] [Indexed: 11/21/2022] Open
Abstract
Diagnosis of intestinal vasculitis is often challenging due to the non-specific clinical and imaging findings. Vasculitides with gastrointestinal (GI) manifestations are rare, but their diagnosis holds immense significance as late or missed recognition can result in high mortality rates. Given the resemblance of radiologic findings with some other entities, GI vasculitis is often overlooked on small bowel studies done using computed tomography/magnetic resonance enterography (CTE/MRE). Hereon, we reviewed radiologic findings of vasculitis with gastrointestinal involvement on CTE and MRE. The variety of findings on MRE/CTE depend upon the size of the involved vessels. Signs of intestinal ischemia, e.g., mural thickening, submucosal edema, mural hyperenhancement, and restricted diffusion on diffusion-weighted imaging, are common in intestinal vasculitis. Involvement of the abdominal aorta and the major visceral arteries is presented as concentric mural thickening, transmural calcification, luminal stenosis, occlusion, aneurysmal changes, and collateral vessels. Such findings can be observed particularly in large- and medium-vessel vasculitis. The presence of extra-intestinal findings, including within the liver, kidneys, or spleen in the form of focal areas of infarction or heterogeneous enhancement due to microvascular involvement, can be another radiologic clue in diagnosis of vasculitis. The link between the clinical/laboratory findings and MRE/CTE abnormalities needs to be corresponded when it comes to the diagnosis of intestinal vasculitis.
Collapse
Affiliation(s)
- Mehrnam Amouei
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Sara Momtazmanesh
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Hoda Kavosi
- Department of Rheumatology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Ali Shirkhoda
- Department of Radiological Science, University of California at Irvine, Irvine, USA
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran.
| |
Collapse
|
3
|
Santiago MB, Paz A. Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know. J Clin Rheumatol 2021; 27:73-79. [PMID: 33315786 DOI: 10.1097/rhu.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.
Collapse
Affiliation(s)
| | - Adriane Paz
- From the Hospital Universitário Professor Edgard Santos
| |
Collapse
|
4
|
Sato M, Yoshida Y, Sugimoto T, Kishimoto S, Omoto T, Watanabe H, Tokunaga T, Yukawa K, Kohno H, Mokuda S, Nojima T, Hirata S, Sugiyama E. Asymptomatic coronary aneurysms in a patient with eosinophilic granulomatosis with polyangiitis who developed a digital gangrene. Mod Rheumatol Case Rep 2020; 5:130-136. [PMID: 32791887 DOI: 10.1080/24725625.2020.1810404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A 33-year-old male with a history of bronchial asthma and allergic rhinitis was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) eight years ago. The diagnosis was based on the presence of fever, remarkable eosinophilia, and painful digital ulcer. His signs and symptoms improved with a moderate dose of glucocorticoids. Thereafter, he was lost to follow-up, failing to attend any of the scheduled appointments. Three years later, he presented with painful digital gangrene on the lateral fold of the right ring fingernail and abdominal pain triggered by meals. Angiography showed multiple occlusions and severe stenoses of the peripheral arteries and coronary aneurysms, which confirmed the diagnosis of medium vessel vasculitis of the coronary and peripheral arteries due to flare up of EGPA. EGPA predominantly affects the small-sized vessels, but rarely the medium-sized vessels. Coronary vasculitis might occur asymptomatically, until the coronary stenosis becomes severe or myocardial infarction develops; hence, its prevalence is underestimated. In this case, a digital gangrene prompted us to perform a systemic angiography, leading to the diagnosis of coronary vasculitis. Careful observation for coronary lesions is necessary in patients with EGPA who develop digital gangrene.
Collapse
Affiliation(s)
- Mayu Sato
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuji Omoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Rheumatology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hirofumi Watanabe
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tadahiro Tokunaga
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazutoshi Yukawa
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroki Kohno
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takaki Nojima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| |
Collapse
|
5
|
Wang FH, Yang NN, Liu F, Tian H. Unexplained huge liver infarction presenting as a tumor with bleeding: A case report. World J Clin Cases 2020; 8:2016-2022. [PMID: 32518795 PMCID: PMC7262724 DOI: 10.12998/wjcc.v8.i10.2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/26/2020] [Accepted: 04/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Liver infarction is a rare necrotic lesion due to the dual blood supply consisting of the hepatic artery and portal vein. The absence of specific clinical manifestations and imaging appearances usually leads to misdiagnosis and poor prognosis. Thus, the precise diagnosis of liver infarction always requires imaging studies, serum studies, and possible liver biopsy. CASE SUMMARY We report a case of 31-year-old man who developed a huge liver infarction. Persistent right upper abdominal pain and intermittent fever were the main symptoms in this patient. Computed tomography revealed a huge irregular lesion with a maximum diameter of 12.7 cm in the right lobe of the liver. Three-dimensional reconstruction was performed and no significant interruption of the main hepatic vessels was observed. The lesion was initially considered to be a malignant tumor with internal bleeding. Laparoscopic right hepatectomy was performed, and pathology indicated a rare liver infarction. The patient recovered well and was discharged on postoperative day 21. No fever or abnormal liver function were reported in the subsequent 6 mo. CONCLUSION In patients with a huge liver infarction, early surgical intervention may be beneficial.
Collapse
Affiliation(s)
- Fu-Hai Wang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
| | - Ning-Ning Yang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Chest Hospital Affiliated to Shandong University, Jinan 250013, Shandong Province, China
| | - Feng Liu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
| | - Hu Tian
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
| |
Collapse
|
6
|
A delayed diagnosis of eosinophilic granulomatosis with polyangiitis complicated with extensive artery occlusion of lower extremities in children: case report and literature review. Pediatr Rheumatol Online J 2019; 17:26. [PMID: 31138304 PMCID: PMC6537187 DOI: 10.1186/s12969-019-0331-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/17/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis in children. A delayed or missed diagnosis of pediatric EGPA is common, owing to the atypical clinical manifestation and limited recognition of this disorder. The vasculitis in EGPA typically involves small to medium size vessels. Extensive occlusion of arteries in the extremities was being extremely rare and has never been reported in children. CASE PRESENTATION A 10-year and 10-month-old girl with recurrent wheezing and breathlessness during exercise, was initially diagnosed with asthma at the age of five years. Despite unexplained manifestations, including intermittent remarkably increased eosinophilia, uncontrolled allergic rhinitis, and recurrent petechia, from the onset of asthma through to its remission, the consideration of EGPA was completely ignored until the patient presented with aggravated petechia and severe ulceration of the lower extremities, associated with extensive stenosis and/or occlusion of the arteries of the shank and foot. Given her history of asthma, eosinophilia, allergic rhinitis, mononeuropathy, pulmonary infiltrates, and vasculitis confirmed by the skin biopsy, the diagnosis of EGPA was ultimately confirmed. Regrettably, the initial inappropriate and irrational use of corticosteroid failed to relieve the symptoms until more aggressive treatment with intravenous methylprednisolone was started. This was followed by methotrexate treatment, with tapering of prednisone, without relapse over a six-month follow-up. CONCLUSIONS Pediatric rheumatologists should be alert to the possibility of EGPA in children with refractory asthma associated with unexplained manifestations, and should be aware of the thromboembolic complications as vascular sequelae of EGPA.
Collapse
|
7
|
Fontaine C, Staumont-Sallé D, Hatron PY, Cotten A, Couturier C. The hand in systemic diseases other than rheumatoid arthritis. ACTA ACUST UNITED AC 2014; 33:155-73. [DOI: 10.1016/j.main.2014.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 12/24/2013] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
|
8
|
Characteristics, prognosis, and outcomes of cutaneous ischemia and gangrene in systemic necrotizing vasculitides: A retrospective multicenter study. Semin Arthritis Rheum 2014; 43:681-8. [DOI: 10.1016/j.semarthrit.2013.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 09/04/2013] [Accepted: 09/13/2013] [Indexed: 11/23/2022]
|
9
|
Kim HS, Jeong HK, Kim DH, Yu J, Kim Y, Koh YI. A case of churg-strauss syndrome: evidence of eosinophilic vasculitis on liver biopsy. ALLERGY ASTHMA & RESPIRATORY DISEASE 2013. [DOI: 10.4168/aard.2013.1.2.164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hyoung Sang Kim
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyung Ki Jeong
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Hyun Kim
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| | - Jieun Yu
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| | - Young Kim
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Il Koh
- Department of Allergy, Asthma and Clinical Immunology, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
10
|
Harada M, Oe S, Shibata M, Taguchi M, Matsuhashi T, Hiura M, Abe S, Harada R, Shimajiri S. Churg-Strauss syndrome manifesting as cholestasis and diagnosed by liver biopsy. Hepatol Res 2012; 42:940-4. [PMID: 22882337 DOI: 10.1111/j.1872-034x.2012.00993.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A 56-year-old woman was referred to our hospital due to fever and cholestatic liver dysfunction. Her eosinophil count was normal and she had no abdominal pain or neurological manifestations. We performed a liver biopsy and found fibrinoid necrosis of the hepatic artery with granulomatous reaction and eosinophilic infiltration in the portal area in the liver. Later, sensory abnormalities of the arms and legs appeared and the eosinophil count increased. Serum immunoglobulin E and immunoglobulin G4 were elevated and rheumatoid factor was strongly positive. Endoscopic retrograde cholangiopancreatography revealed no abnormality of the bile duct and pancreatic duct. We made a diagnosis of Churg-Strauss syndrome and began corticosteroid treatment. Fever and liver function immediately improved. In the present patient, Churg-Strauss syndrome manifested first in the liver, before hypereosinophilia and neural manifestations. We believe that Churg-Strauss syndrome is an autoimmune liver disease, and it is important to recognize that the liver may be involved in Churg-Strauss syndrome.
Collapse
Affiliation(s)
- Masaru Harada
- Third Department of Internal Medicine Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
BOOPATHY KS, RAJENDRAN CP, RUKMANGATHARAJAN S, RAJESWARI S, RAVICHANDRAN R, VASANTHY N. ChurgStrauss syndrome with peripheral gangrene and severe renal failure. Int J Rheum Dis 2008. [DOI: 10.1111/j.1756-185x.2008.00357.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
12
|
Falkensammer J, Bonatti H, Dickson RC, Norman K, Nguyen J, Hinder R, Aranda-Michel J. Successful liver transplantation and treatment of recurrent hepatitis C using pegylated alpha-interferon in a patient with Churg-Strauss disease. Transpl Int 2007; 20:190-4. [PMID: 17239028 DOI: 10.1111/j.1432-2277.2006.00415.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Churg-Strauss disease (CSD) is a rare allergic disorder that is associated with vasculitis, peripheral eosinophilia and allergic asthma. We report on successful liver transplantation in a patient with CSD who suffered from chronic hepatitis C. Recurrent hepatitis C and CSD were ultimately managed by the application of pegylated interferon.
Collapse
|
13
|
Cuchacovich R, Justiniano M, Espinoza LR. Churg-Strauss syndrome associated with leukotriene receptor antagonists (LTRA). Clin Rheumatol 2007; 26:1769-71. [PMID: 17256102 DOI: 10.1007/s10067-006-0510-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Accepted: 11/27/2006] [Indexed: 10/23/2022]
Abstract
Churg-Strauss syndrome (CSS) is a rare vasculitic disorder that generally occurs in patients with bronchial asthma. CSS is being increasingly recognized in asthmatic patients treated with leukotriene receptor antagonists. However, the nature of this relationship remains to be elucidated. The present report describes three asthmatic patients who developed clinical manifestations highly suggestive of CSS, although one patient lacked the presence of eosinophilia. The patient, however, exhibited biopsy-proven cutaneous necrotizing vasculitis, which improved after withdrawal of montelukast. The second patient presented with systemic constitutional signs including fever, malaise, arthralgias, clinical jaundice, peripheral blood eosinophilia, and biopsy-proven eosinophilic hepatitis. The third patient also had circulating eosinophilia, scleritis, and arthritis. All patients improved after discontinuation of the leukotriene receptor antagonist (montelukast).
Collapse
Affiliation(s)
- R Cuchacovich
- Division of Rheumatology, Department of Internal Medicine, LSU Health Sciences Center, 2020 Gravier Street, 7th Floor, Box E-20, New Orleans, LA 70115, USA
| | | | | |
Collapse
|
14
|
Suchard JR, McLaren CJ. Clinicopathological Conference: A 38-year-old Man with Respiratory Failure—The Case of the Underground Illness. Acad Emerg Med 2005. [DOI: 10.1111/j.1553-2712.2005.tb01482.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|