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Alruwaili Y, Jacobs MB, Hasenkampf NR, Tardo AC, McDaniel CE, Embers ME. Superior efficacy of combination antibiotic therapy versus monotherapy in a mouse model of Lyme disease. Front Microbiol 2023; 14:1293300. [PMID: 38075920 PMCID: PMC10703379 DOI: 10.3389/fmicb.2023.1293300] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/08/2023] [Indexed: 02/08/2024] Open
Abstract
Lyme disease (LD) results from the most prevalent tick-borne infection in North America, with over 476,000 estimated cases annually. The disease is caused by Borrelia burgdorferi (Bb) sensu lato which transmits through the bite of Ixodid ticks. Most cases treated soon after infection are resolved by a short course of oral antibiotics. However, 10-20% of patients experience chronic symptoms because of delayed or incomplete treatment, a condition called Post-Treatment Lyme Disease (PTLD). Some Bb persists in PTLD patients after the initial course of antibiotics and an effective treatment to eradicate the persistent Bb is needed. Other organisms that cause persistent infections, such as M. tuberculosis, are cleared using a combination of therapies rather than monotherapy. A group of Food and Drug Administration (FDA)-approved drugs previously shown to be efficacious against Bb in vitro were used in monotherapy or in combination in mice infected with Bb. Different methods of detection were used to assess the efficacy of the treatments in the infected mice including culture, xenodiagnosis, and molecular techniques. None of the monotherapies eradicated persistent Bb. However, 4 dual combinations (doxycycline + ceftriaxone, dapsone + rifampicin, dapsone + clofazimine, doxycycline + cefotaxime) and 3 triple combinations (doxycycline + ceftriaxone+ carbomycin, doxycycline + cefotaxime+ loratadine, dapsone+ rifampicin+ clofazimine) eradicated persistent Bb infections. These results suggest that combination therapy should be investigated in preclinical studies for treating human Lyme disease.
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Affiliation(s)
- Yasir Alruwaili
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka, Saudi Arabia
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
| | - Mary B. Jacobs
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
| | - Nicole R. Hasenkampf
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
| | - Amanda C. Tardo
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
| | - Celine E. McDaniel
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
| | - Monica E. Embers
- Division of Immunology, Tulane National Primate Research Center, Tulane University, Covington, LA, United States
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
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Adkison H, Embers ME. Lyme disease and the pursuit of a clinical cure. Front Med (Lausanne) 2023; 10:1183344. [PMID: 37293310 PMCID: PMC10244525 DOI: 10.3389/fmed.2023.1183344] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/10/2023] [Indexed: 06/10/2023] Open
Abstract
Lyme disease, caused by the spirochete Borrelia burgdorferi, is the most common vector-borne illness in the United States. Many aspects of the disease are still topics of controversy within the scientific and medical communities. One particular point of debate is the etiology behind antibiotic treatment failure of a significant portion (10-30%) of Lyme disease patients. The condition in which patients with Lyme disease continue to experience a variety of symptoms months to years after the recommended antibiotic treatment is most recently referred to in the literature as post treatment Lyme disease syndrome (PTLDS) or just simply post treatment Lyme disease (PTLD). The most commonly proposed mechanisms behind treatment failure include host autoimmune responses, long-term sequelae from the initial Borrelia infection, and persistence of the spirochete. The aims of this review will focus on the in vitro, in vivo, and clinical evidence that either validates or challenges these mechanisms, particularly with regard to the role of the immune response in disease and resolution of the infection. Next generation treatments and research into identifying biomarkers to predict treatment responses and outcomes for Lyme disease patients are also discussed. It is essential that definitions and guidelines for Lyme disease evolve with the research to translate diagnostic and therapeutic advances to patient care.
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Affiliation(s)
| | - Monica E. Embers
- Division of Immunology, Tulane National Primate Research Center, Tulane University Health Sciences, Covington, LA, United States
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Verschoor YL, Vrijlandt A, Spijker R, van Hest RM, ter Hofstede H, van Kempen K, Henningsson AJ, Hovius JW. Persistent Borrelia burgdorferi Sensu Lato Infection after Antibiotic Treatment: Systematic Overview and Appraisal of the Current Evidence from Experimental Animal Models. Clin Microbiol Rev 2022; 35:e0007422. [PMID: 36222707 PMCID: PMC9769629 DOI: 10.1128/cmr.00074-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Lyme borreliosis is caused by spirochetes belonging to the Borrelia burgdorferi sensu lato group, which are transmitted by Ixodes tick species living in the temperate climate zones of the Northern Hemisphere. The clinical manifestations of Lyme borreliosis are diverse and treated with oral or intravenous antibiotics. In some patients, long-lasting and debilitating symptoms can persist after the recommended antibiotic treatment. The etiology of such persisting symptoms is under debate, and one hypothesis entails persistent infection by a subset of spirochetes after antibiotic therapy. Here, we review and appraise the experimental evidence from in vivo animal studies on the persistence of B. burgdorferi sensu lato infection after antibiotic treatment, focusing on the antimicrobial agents doxycycline and ceftriaxone. Our review indicates that some in vivo animal studies found sporadic positive cultures after antibiotic treatment. However, this culture positivity often seemed to be related to inadequate antibiotic treatment, and the few positive cultures in some studies could not be reproduced in other studies. Overall, current results from animal studies provide insufficient evidence for the persistence of viable and infectious spirochetes after adequate antibiotic treatment. Borrelial nucleic acids, on the contrary, were frequently detected in these animal studies and may thus persist after antibiotic treatment. We put forward that research into the pathogenesis of persisting complaints after antibiotic treatment for Lyme borreliosis in humans should be a top priority, but future studies should most definitely also focus on explanations other than persistent B. burgdorferi sensu lato infection after antibiotic treatment.
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Affiliation(s)
- Y. L. Verschoor
- Amsterdam UMC, Location University of Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC Multidisciplinary Lyme Borreliosis Center, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam, The Netherlands
| | - A. Vrijlandt
- Amsterdam UMC, Location University of Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC Multidisciplinary Lyme Borreliosis Center, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam, The Netherlands
| | - R. Spijker
- Amsterdam UMC, Location University of Amsterdam, Amsterdam Public Health, Medical Library, Amsterdam, The Netherlands
| | - R. M. van Hest
- Amsterdam UMC, Location University of Amsterdam, Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam, The Netherlands
| | - H. ter Hofstede
- Department of Internal Medicine, Section of Infectious Diseases, Lyme Borreliosis Outpatient Clinic, Radboudumc, Nijmegen, The Netherlands
| | | | - A. J. Henningsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Microbiology in Jönköping, Region Jönköping County, Linköping University, Linköping, Sweden
| | - J. W. Hovius
- Amsterdam UMC, Location University of Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC Multidisciplinary Lyme Borreliosis Center, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Center for Experimental and Molecular Medicine, Amsterdam, The Netherlands
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Abstract
Most patients with Lyme disease will fully recover with recommended antibiotic therapy. However, some patients report persisting nonspecific symptoms after treatment, referred to as posttreatment Lyme disease symptoms (PTLDs) or syndrome (PTLDS), depending on the degree to which the individual's symptoms impact their quality of life. PTLDs occur in a portion of patients diagnosed with chronic Lyme disease (CLD), a controversial term describing different patient populations, diagnosed based on unvalidated tests and criteria. Practitioners should review the evidence for the Lyme disease diagnosis and not overlook unrelated conditions. Current evidence shows that prolonged antibiotic therapy provides little benefit and carries significant risk. Further research to elucidate the mechanisms underlying persistent symptoms after Lyme disease and to understand CLD is needed.
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Affiliation(s)
- Adriana Marques
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, BG 10 RM 12C118 MSC 1888 10 Center, Bethesda, MD 20892-1888, USA.
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Cabello FC, Embers ME, Newman SA, Godfrey HP. Borreliella burgdorferi Antimicrobial-Tolerant Persistence in Lyme Disease and Posttreatment Lyme Disease Syndromes. mBio 2022; 13:e0344021. [PMID: 35467428 PMCID: PMC9239140 DOI: 10.1128/mbio.03440-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The annual incidence of Lyme disease, caused by tick-transmitted Borreliella burgdorferi, is estimated to be at least 476,000 cases in the United States and many more worldwide. Ten to 20% of antimicrobial-treated Lyme disease patients display posttreatment Lyme disease syndrome (PTLDS), a clinical complication whose etiology and pathogenesis remain uncertain. Autoimmunity, cross-reactivity, molecular mimicry, coinfections, and borrelial tolerance to antimicrobials/persistence have been hypothesized and studied as potential causes of PTLDS. Studies of borrelial tolerance/persistence in vitro in response to antimicrobials and experimental studies in mice and nonhuman primates, taken together with clinical reports, have revealed that B. burgdorferi becomes tolerant to antimicrobials and may sometimes persist in animals and humans after the currently recommended antimicrobial treatment. Moreover, B. burgdorferi is pleomorphic and can generate viable-but-nonculturable bacteria, states also involved in antimicrobial tolerance. The multiple regulatory pathways and structural genes involved in mediating this tolerance to antimicrobials and environmental stressors by persistence might include the stringent (rel and dksA) and host adaptation (rpoS) responses, sugar metabolism (glpD), and polypeptide transporters (opp). Application of this recently reported knowledge to clinical studies can be expected to clarify the potential role of bacterial antibacterial tolerance/persistence in Lyme disease and PTLDS.
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Affiliation(s)
- Felipe C. Cabello
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York, USA
| | - Monica E. Embers
- Division of Immunology, Tulane National Primate Research Center, Tulane University Health Sciences, Covington, Louisiana, USA
| | - Stuart A. Newman
- Department of Cell Biology and Anatomy, New York Medical College, Valhalla, New York, USA
| | - Henry P. Godfrey
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York, USA
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A Review of Post-treatment Lyme Disease Syndrome and Chronic Lyme Disease for the Practicing Immunologist. Clin Rev Allergy Immunol 2021; 62:264-271. [PMID: 34687445 DOI: 10.1007/s12016-021-08906-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 12/22/2022]
Abstract
Lyme disease is an infection caused by Borrelia burgdorferi sensu lato, which is transmitted to humans through the bite of an infected Ixodes tick. The majority of patients recover without complications with antibiotic therapy. However, for a minority of patients, accompanying non-specific symptoms can persist for months following completion of therapy. The constellation of symptoms such as fatigue, cognitive dysfunction, and musculoskeletal pain that persist beyond 6 months and are associated with disability have been termed post-treatment Lyme disease syndrome (PTLDS), a subset of a broader term "chronic Lyme disease." Chronic Lyme disease is a broad, vaguely defined term that is used to describe patients with non-specific symptoms that are attributed to a presumed persistent Borrelia burgdorferi infection in patients who may or may not have evidence of either previous or current Lyme disease. The diagnoses of chronic Lyme disease and of PTLDS have become increasingly relevant to the practice of immunologists due to referrals for consultation or for intravenous immunoglobulin (IVIG) treatment. This review aims to explore the relationship between chronic Lyme disease, post-treatment Lyme disease syndrome, and the immune system. Here, we review the current literature on (1) issues in conventional and alternative diagnostic testing for Lyme disease, (2) the hypothesis that B. burgdorferi infection can persist despite appropriate use of recommended antibiotics, (3) current theories regarding B. burgdorferi's role in causing both immune dysregulation and protracted symptoms, and (4) the use of IVIG for the treatment of Lyme disease.
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The Brilliance of Borrelia: Mechanisms of Host Immune Evasion by Lyme Disease-Causing Spirochetes. Pathogens 2021; 10:pathogens10030281. [PMID: 33801255 PMCID: PMC8001052 DOI: 10.3390/pathogens10030281] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 01/31/2023] Open
Abstract
Lyme disease (LD) has become the most common vector-borne illness in the northern hemisphere. The causative agent, Borrelia burgdorferi sensu lato, is capable of establishing a persistent infection within the host. This is despite the activation of both the innate and adaptive immune responses. B. burgdorferi utilizes several immune evasion tactics ranging from the regulation of surface proteins, tick saliva, antimicrobial peptide resistance, and the disabling of the germinal center. This review aims to cover the various methods by which B. burgdorferi evades detection and destruction by the host immune response, examining both the innate and adaptive responses. By understanding the methods employed by B. burgdorferi to evade the host immune response, we gain a deeper knowledge of B. burgdorferi pathogenesis and Lyme disease, and gain insight into how to create novel, effective treatments.
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Trevisan G, Bonin S, Ruscio M. A Practical Approach to the Diagnosis of Lyme Borreliosis: From Clinical Heterogeneity to Laboratory Methods. Front Med (Lausanne) 2020; 7:265. [PMID: 32793606 PMCID: PMC7390863 DOI: 10.3389/fmed.2020.00265] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/14/2020] [Indexed: 12/05/2022] Open
Abstract
Clinical evaluation of Lyme Borreliosis (LB) is the starting point for its diagnosis. The patient's medical history and clinical symptoms are fundamental for disease recognition. The heterogeneity in clinical manifestations of LB can be related to different causes, including the different strains of Borrelia, possible co-infection with other tick transmitted pathogens, and its interactions with the human host. This review aims at describing the heterogeneous symptoms of Lyme Borreliosis, as well as offering a practical approach for recognition of the disease, both in terms of clinical features and diagnostic/research tools.
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Affiliation(s)
- Giusto Trevisan
- DSM-Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Serena Bonin
- DSM-Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Maurizio Ruscio
- ASU GI-Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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Chaconas G, Castellanos M, Verhey TB. Changing of the guard: How the Lyme disease spirochete subverts the host immune response. J Biol Chem 2020; 295:301-313. [PMID: 31753921 PMCID: PMC6956529 DOI: 10.1074/jbc.rev119.008583] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Lyme disease, also known as Lyme borreliosis, is the most common tick-transmitted disease in the Northern Hemisphere. The disease is caused by the bacterial spirochete Borrelia burgdorferi and other related Borrelia species. One of the many fascinating features of this unique pathogen is an elaborate system for antigenic variation, whereby the sequence of the surface-bound lipoprotein VlsE is continually modified through segmental gene conversion events. This perpetual changing of the guard allows the pathogen to remain one step ahead of the acquired immune response, enabling persistent infection. Accordingly, the vls locus is the most evolutionarily diverse genetic element in Lyme disease-causing borreliae. Small stretches of information are transferred from a series of silent cassettes in the vls locus to generate an expressed mosaic vlsE gene version that contains genetic information from several different silent cassettes, resulting in ∼1040 possible vlsE sequences. Yet, despite its extreme evolutionary flexibility, the locus has rigidly conserved structural features. These include a telomeric location of the vlsE gene, an inverse orientation of vlsE and the silent cassettes, the presence of nearly perfect inverted repeats of ∼100 bp near the 5' end of vlsE, and an exceedingly high concentration of G runs in vlsE and the silent cassettes. We discuss the possible roles of these evolutionarily conserved features, highlight recent findings from several studies that have used next-generation DNA sequencing to unravel the switching process, and review advances in the development of a mini-vls system for genetic manipulation of the locus.
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Affiliation(s)
- George Chaconas
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| | - Mildred Castellanos
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Theodore B Verhey
- Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta T2N 4N1, Canada
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Sapi E, Kasliwala RS, Ismail H, Torres JP, Oldakowski M, Markland S, Gaur G, Melillo A, Eisendle K, Liegner KB, Libien J, Goldman JE. The Long-Term Persistence of Borrelia burgdorferi Antigens and DNA in the Tissues of a Patient with Lyme Disease. Antibiotics (Basel) 2019; 8:antibiotics8040183. [PMID: 31614557 PMCID: PMC6963883 DOI: 10.3390/antibiotics8040183] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 01/29/2023] Open
Abstract
Whether Borrelia burgdorferi, the causative agent of Lyme disease, can persist for long periods in the human body has been a controversial question. The objective of this study was to see if we could find B. burgdorferi in a Lyme disease patient after a long clinical course and after long-term antibiotic treatment. Therefore, we investigated the potential presence of B. burgdorferi antigens and DNA in human autopsy tissues from a well-documented serum-, PCR-, and culture-positive Lyme disease patient, a 53-year-old female from northern Westchester County in the lower Hudson Valley Region of New York State, who had received extensive antibiotic treatments during extensive antibiotic treatments over the course of her 16-year-long illness. We also asked what form the organism might take, with special interest in the recently found antibiotic-resistant aggregate form, biofilm. We also examined the host tissues for the presence of inflammatory markers such as CD3+ T lymphocytes. Autopsy tissue sections of the brain, heart, kidney, and liver were analyzed by histological and immunohistochemical methods (IHC), confocal microscopy, fluorescent in situ hybridization (FISH), polymerase chain reaction (PCR), and whole-genome sequencing (WGS)/metagenomics. We found significant pathological changes, including borrelial spirochetal clusters, in all of the organs using IHC combined with confocal microscopy. The aggregates contained a well-established biofilm marker, alginate, on their surfaces, suggesting they are true biofilm. We found B. burgdorferi DNA by FISH, polymerase chain reaction (PCR), and an independent verification by WGS/metagenomics, which resulted in the detection of B. burgdorferi sensu stricto specific DNA sequences. IHC analyses showed significant numbers of infiltrating CD3+ T lymphocytes present next to B. burgdorferi biofilms. In summary, we provide several lines of evidence that suggest that B. burgdorferi can persist in the human body, not only in the spirochetal but also in the antibiotic-resistant biofilm form, even after long-term antibiotic treatment. The presence of infiltrating lymphocytes in the vicinity of B. burgdorferi biofilms suggests that the organism in biofilm form might trigger chronic inflammation.
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Affiliation(s)
- Eva Sapi
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Rumanah S Kasliwala
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Hebo Ismail
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Jason P Torres
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Michael Oldakowski
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Sarah Markland
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Gauri Gaur
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Anthony Melillo
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT 06516, USA.
| | - Klaus Eisendle
- Central Teaching Hospital Bolzano L Böhlerstr, 539100 Bolzano, Italy.
| | - Kenneth B Liegner
- Private practice, 592 Route 22, Suite 1B, Pawling, NY 12564, USA.
- Northwell System, Northern Westchester Hospital, Mount Kisco, NY 10549, USA.
- Health Quest System, Sharon Hospital, Sharon, CT 06069, USA.
| | - Jenny Libien
- Department of Pathology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA.
| | - James E Goldman
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10031, USA.
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