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Nakamura R, Kitamura A, Tsukamoto T, Tamura R, Ogawa N, Yamakawa I, Kim H, Kawai M, Sanada M, Urushitani M. The Effect of Intravenous Methylprednisolone on Recurrent Exacerbation in Hematologic Malignancy-associated Progressive Multifocal Leukoencephalopathy. Intern Med 2021; 60:1287-1291. [PMID: 33229808 PMCID: PMC8112991 DOI: 10.2169/internalmedicine.5917-20] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We herein report a 65-year-old man with progressive multifocal leukoencephalopathy (PML) after 2-year remission from acute myeloid leukemia who developed recurrent episodes of left hemiparesis with gadolinium enhancement on magnetic resonance imaging. Steroid pulse therapy for each exacerbation induced clinical and radiological improvement, suggesting that exacerbations are an excessive immune response to the JC virus and distinct from immune reconstitution inflammatory syndrome (IRIS). Although glucocorticoids are recommended only for IRIS, steroid pulse therapy should be considered as a therapeutic option in cases of exacerbation of hematologic malignancy-associated PML. Importantly, neuroimaging is not sufficient to differentiate excessive inflammation from a controlled inflammatory response, for which steroids are not recommended.
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Affiliation(s)
- Ryutaro Nakamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Akihiro Kitamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | | | - Ryota Tamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Nobuhiro Ogawa
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Isamu Yamakawa
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Hyoh Kim
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Michihiro Kawai
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Mitsuru Sanada
- Department of Neurology, Shiga University of Medical Science, Japan
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Graf LM, Rosenkranz SC, Hölzemer A, Hagel C, Goebell E, Jordan S, Friese MA, Addo MM, Schulze Zur Wiesch J, Beisel C. Clinical Presentation and Disease Course of 37 Consecutive Cases of Progressive Multifocal Leukoencephalopathy (PML) at a German Tertiary-Care Hospital: A Retrospective Observational Study. Front Neurol 2021; 12:632535. [PMID: 33613439 PMCID: PMC7890249 DOI: 10.3389/fneur.2021.632535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/04/2021] [Indexed: 01/27/2023] Open
Abstract
Background: Progressive multifocal leukoencephalopathy (PML) caused by JCV is a rare but frequently fatal disease of the central nervous system, usually affecting immunocompromised individuals. Our study aims to expand the data on patient characteristics, diagnosis, clinical course, possible PML-directed treatment, and outcome of patients with PML at a German tertiary-care hospital. Methods:In this single-center observational cohort study, 37 consecutive patients with a confirmed diagnosis of PML seen at the University Medical Center Hamburg-Eppendorf from 2013 until 2019 were retrospectively analyzed by chart review with a special focus on demographics, risk factors, and clinical aspects as well as PML-directed treatment and survival. Results:We identified 37 patients with definite, probable, and possible PML diagnosis. 36 patients (97%) had underlying immunosuppressive disorders such as HIV/AIDS (n = 17; 46%), previous treatment with monoclonal antibodies (n = 6; 16%), hematological or oncological malignancies (n = 6; 16%), sarcoidosis (n = 5; 14%), solid organ transplantation (n = 1; 3%), and diagnosis of mixed connective tissue disease (n = 1; 3%). In only one patient no evident immunocompromised condition was detected (n = 1; 3%). Treatment attempts to improve the outcome of PML were reported in 13 patients (n = 13; 35%). Twenty seven percent of patients were lost to follow-up (n = 10). Twenty four-month survival rate after diagnosis of PML was 56% (n = 15). Conclusion: This interdisciplinary retrospective study describes epidemiology, risk factors, clinical course, and treatment trials in patients with PML at a German tertiary-care hospital. Acquired immunosuppression due to HIV-1 constituted the leading cause of PML in this monocenter cohort.
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Affiliation(s)
- Lisa M Graf
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sina C Rosenkranz
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angelique Hölzemer
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.,Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Christian Hagel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Einar Goebell
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Jordan
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marylyn M Addo
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Claudia Beisel
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.,Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
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Schwenk HT, Khan A, Kohlman K, Bertaina A, Cho S, Montoya JG, Contopoulos-Ioannidis DG. Toxoplasmosis in Pediatric Hematopoietic Stem Cell Transplantation Patients. Transplant Cell Ther 2020; 27:292-300. [PMID: 33840441 DOI: 10.1016/j.jtct.2020.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/05/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
Infection due to the protozoa Toxoplasma gondii can be life-threatening in hematopoietic stem cell transplantation (HSCT) recipients. Most cases of toxoplasmosis in HSCT recipients result from reactivation of latent infection in individuals who were Toxoplasma-seropositive before transplantation and did not receive appropriate prophylaxis. Pretransplantation screening with Toxoplasma IgG and IgM antibodies is suggested for all allogeneic HSCT recipients and their donors and all autologous HSCT recipients. Prevention of toxoplasmosis in T. gondii-seropositive HSCT recipients requires primary prophylaxis, preemptive screening, or both. Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent for Toxoplasma prophylaxis and should be continued for 6 months or until the patient is no longer receiving immunosuppression, whichever is longer, assuming that immune reconstitution has occurred. Preemptive weekly screening with whole blood Toxoplasma PCR should be considered for seropositive HSCT recipients if prophylaxis cannot be given or if prophylaxis other than TMP-SMX is used. The signs, symptoms, and radiographic findings of toxoplasmosis in HSCT recipients can be nonspecific, and the diagnosis requires a high degree of suspicion. Common presentations include fever, encephalopathy with mental status changes or seizures, and pneumonia. A Toxoplasma PCR analysis from whole blood (and other body fluids/tissues according to clinical symptoms) should be obtained in patients in whom there is a concern for toxoplasmosis. Treatment with oral pyrimethamine, sulfadiazine, and leucovorin for at least 6 weeks is the first-line therapy and should be followed by secondary prophylaxis. In this article, we review the published literature regarding the epidemiology, clinical presentation, treatment, and prevention of toxoplasmosis in HSCT recipients.
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Affiliation(s)
- Hayden T Schwenk
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
| | - Aslam Khan
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Krystal Kohlman
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Alice Bertaina
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Stephanie Cho
- Community Health and Prevention Research Master's Graduate Program, Stanford University School of Medicine, Stanford, California
| | - Jose G Montoya
- Dr Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto Medical Foundation, Palo Alto, California
| | - Despina G Contopoulos-Ioannidis
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; Dr Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto Medical Foundation, Palo Alto, California
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Beyond Cytomegalovirus and Epstein-Barr Virus: a Review of Viruses Composing the Blood Virome of Solid Organ Transplant and Hematopoietic Stem Cell Transplant Recipients. Clin Microbiol Rev 2020; 33:33/4/e00027-20. [PMID: 32847820 DOI: 10.1128/cmr.00027-20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Viral primary infections and reactivations are common complications in patients after solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) and are associated with high morbidity and mortality. Among these patients, viral infections are frequently associated with viremia. Beyond the usual well-known viruses that are part of the routine clinical management of transplant recipients, numerous other viral signatures or genomes can be identified in the blood of these patients. The identification of novel viral species and variants by metagenomic next-generation sequencing has opened up a new field of investigation and new paradigms. Thus, there is a need to thoroughly describe the state of knowledge in this field with a review of all viral infections that should be scrutinized in high-risk populations. Here, we review the eukaryotic DNA and RNA viruses identified in blood, plasma, or serum samples of pediatric and adult SOT/HSCT recipients and the prevalence of their detection, with a particular focus on recently identified viruses and those for which their potential association with disease remains to be investigated, such as members of the Polyomaviridae, Anelloviridae, Flaviviridae, and Astroviridae families. Current knowledge of the clinical significance of these viral infections with associated viremia among transplant recipients is also discussed. To ensure a comprehensive description in these two populations, individuals described as healthy (mostly blood donors) are considered for comparative purposes. The list of viruses that should be on the clinicians' radar is certainly incomplete and will expand, but the challenge is to identify those of possible clinical significance.
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Uzunov M, Demeret S, Nguyen‐Quoc S, Morel V, Bellanger A, Chavez H, Gasnault J, Leblond V, Roos‐Weil D. Postallogeneic transplantation progressive multifocal leukoencephalopathy successfully treated by nivolumab. Br J Haematol 2019; 188:e82-e84. [DOI: 10.1111/bjh.16349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Madalina Uzunov
- Sorbonne Université Service d’Hématologie Clinique Hôpital Pitié‐Salpêtrière APHP Paris France
| | - Sophie Demeret
- Département de Neurologie Sorbonne Université Hôpital Pitié‐Salpêtrière APHP Paris France
| | - Stéphanie Nguyen‐Quoc
- Sorbonne Université Service d’Hématologie Clinique Hôpital Pitié‐Salpêtrière APHP Paris France
| | - Véronique Morel
- Sorbonne Université Service d’Hématologie Clinique Hôpital Pitié‐Salpêtrière APHP Paris France
| | | | - Houria Chavez
- INSERM U1184 Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - Jacques Gasnault
- UF SSR des Maladies Neurovirales Médecine Interne & Immunologie Clinique Centre Hospitalier Universitaire de Bicetre IMVA INSERM Le Kremlin‐Bicêtre France
| | - Véronique Leblond
- Sorbonne Université Service d’Hématologie Clinique Hôpital Pitié‐Salpêtrière APHP Paris France
| | - Damien Roos‐Weil
- Sorbonne Université Service d’Hématologie Clinique Hôpital Pitié‐Salpêtrière APHP Paris France
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Pasca M, Picchioni A, Mazzeo S, Terenzi F, Prestipino E, Fratangelo R, Repice AM, Carlucci G, Massacesi L, Barilaro A. A case of recurrent progressive multifocal leukoencephalopathy after human stem cell transplant, with detection of John Cunningham virus and human herpesvirus 6 on cerebrospinal fluid, treated with Mirtazapine, Olanzapine and Foscarnet. Intractable Rare Dis Res 2019; 8:275-278. [PMID: 31890456 PMCID: PMC6929596 DOI: 10.5582/irdr.2019.01107] [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] [Indexed: 11/05/2022] Open
Abstract
We reported the case of a John Cunningham virus (JCV) and human herpesvirus 6 (HHV-6) mediated progressive multifocal leukoencephalopathy (PML) after human stem cell transplant, reactivated 6 months later in absence of immunosuppressive therapy, successfully treated with anti-5HT2A receptors agents and antiviral therapy. Few cases of JCV and HHV-6 coinfection associated PML are described in literature and the role of HHV-6 in the pathogenesis and prognosis of PML is not completely clear. Our case suggests that, in a possible PML, the research of HHV-6 and JCV should be always performed on cerebrospinal fluid (CSF) and on blood samples and in case of detection of HHV-6 DNA a chromosomally integrated human herpesvirus 6(ciHHV-6) should be excluded. Furthermore we recommend to start an appropriate therapy with antiviral and anti-5HT2A receptors agents in case of possible PML due to JCV and HHV-6 coinfection.
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Affiliation(s)
- Matteo Pasca
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Address correspondence to:Dr. Matteo Pasca, Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Largo Brambilla, 3 - 50134 Florence, Italy. E-mail:
| | - Antonella Picchioni
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
| | - Salvatore Mazzeo
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
| | - Federica Terenzi
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
| | - Elio Prestipino
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
| | - Roberto Fratangelo
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
| | - Anna Maria Repice
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Neurological Division II Careggi University Hospital, Florence, Italy
| | - Giovanna Carlucci
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Neurological Division II Careggi University Hospital, Florence, Italy
| | - Luca Massacesi
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Neurological Division II Careggi University Hospital, Florence, Italy
| | - Alessandro Barilaro
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Neurological Division II Careggi University Hospital, Florence, Italy
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Kartau M, Verkkoniemi-Ahola A, Paetau A, Palomäki M, Janes R, Ristola M, Lappalainen M, Anttila VJ. The Incidence and Predisposing Factors of John Cunningham Virus-Induced Progressive Multifocal Leukoencephalopathy in Southern Finland: A Population-Based Study. Open Forum Infect Dis 2019; 6:ofz024. [PMID: 30815501 PMCID: PMC6386113 DOI: 10.1093/ofid/ofz024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/22/2018] [Accepted: 01/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to assess the prevalence, incidence rate (IR), predisposing factors, survival rate, and diagnostic delay of progressive multifocal leukoencephalopathy (PML) across medical specialties. Another objective was to survey how PML diagnosis was made in the studied cases. Methods This is a cross-sectional retrospective observational study of PML cases across different medical specialties during 2004–2016 in the Finnish Capital Region and Southern Finland. Data were obtained from clinical records, clinical microbiology, pathology and radiology department records, and human immunodeficiency virus (HIV) quality register medical records. Results A total of 31 patients were diagnosed with PML. The prevalence of PML was 1.56 per 100 000 people and the IR was 0.12 per 100 000 individuals per year during 2004–2016. Hematologic malignancies (n = 19) and HIV/acquired immune deficiency syndrome (n = 5) were the most common underlying diseases, and all patients who had malignant diseases had received cancer treatment. Before PML diagnosis, 21 (67.7%) patients were treated with chemotherapy, 14 (45.2%) patients with rituximab, and 1 patient (3.2%) with natalizumab. Two patients (6.5%) had no obvious immunocompromising disease or treatment. Neither gender, age, first symptoms, previous medication, nor underlying disease influenced the survival of PML patients significantly. The 5-year survival rate was poor, at less than 10%. Conclusions The majority of PML patients in our study had a predisposing disease or had immunosuppressive or monoclonal antibody therapy. In the future, broader use of immunosuppressive and immunomodulatory medications may increase incidence of PML among patients with diseases unassociated with PML. Safety screening protocols for John Cunningham virus and PML are important to prevent new PML cases.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Finland
| | - Anders Paetau
- Department of Pathology (Neuropathology), Helsinki University Hospital Laboratory (HUSLAB), Helsinki University Hospital and Helsinki University, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki University Hospital and Helsinki University, Finland
| | - Rita Janes
- Department of Oncology, Helsinki University Hospital and Helsinki University, Finland
| | - Matti Ristola
- Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital and Helsinki University, Finland
| | - Maija Lappalainen
- Laboratory Services (HUSLAB), Department of Virology and Immunology, Helsinki University Hospital and Helsinki University, Finland
| | - Veli-Jukka Anttila
- Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital and Helsinki University, Finland
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Dulamea AO, Lupescu IG. Neurological complications of hematopoietic cell transplantation in children and adults. Neural Regen Res 2018; 13:945-954. [PMID: 29926815 PMCID: PMC6022482 DOI: 10.4103/1673-5374.233431] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) is widely performed for neoplastic and non-neoplastic diseases. HCT involves intravenous infusion of hematopoietic progenitor cells from human leukocyte antigen (HLA)-matched donor (allogeneic) or from the patient (autologous). Before HCT, the patient is prepared with high dose chemotherapy and/or radiotherapy to destroy residual malignant cells and to reduce immunologic resistance. After HCT, chemotherapy is used to prevent graft rejection and graft versus host disease (GvHD). Neurological complications are related to the type of HCT, underlying disease, toxicity of the conditioning regimens, immunosuppression caused by conditioning regimens, vascular complications generated by thrombocytopenia and/or coagulopathy, GvHD and inappropriate immune response. In this review, neurological complications are presented according to time of onset after HCT: (1) early complications (in the first month) - related to harvesting of stem cells, during conditioning (drug toxicity, posterior reversible encephalopathy syndrome), related to pancytopenia, (2) intermediate phase complications (second to sixth month) - central nervous system infections caused by prolonged neutropenia and progressive multifocal leukoencephalopathy due to JC virus, (3) late phase complications (after sixth month) - neurological complications of GvHD, second neoplasms and relapses of the original disease.
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Affiliation(s)
- Adriana Octaviana Dulamea
- University of Medicine and Pharmacy Carol Davila; Department of Neurology, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Gabriela Lupescu
- University of Medicine and Pharmacy Carol Davila; Radiology and Medical Imaging Department, Fundeni Clinical Institute, Bucharest, Romania
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