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Yadav S. Tuberculosis of the Elbow Joint in an Indian Boy: A Rare Entity With a Diagnostic Challenge. Cureus 2024; 16:e58184. [PMID: 38741885 PMCID: PMC11089490 DOI: 10.7759/cureus.58184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Tuberculosis of the bones and joints is an infrequently reported entity. Isolated involvement of the elbow joint is exceedingly rare, even in endemic countries. The diagnosis is an arduous task, especially if it presents in younger age groups. Herein, a case of tuberculosis of the right elbow joint in a seven-year-old Indian child is presented. The diagnosis was challenging due to the vague clinical features and rarity of the disease, but he was diagnosed after a detailed clinical examination along with a radiometric assessment. He was initiated on the appropriate chemotherapy.
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Affiliation(s)
- Sankalp Yadav
- Medicine, Shri Madan Lal Khurana Chest Clinic, New Delhi, IND
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Mahomed N, Kilborn T, Smit EJ, Chu WCW, Young CYM, Koranteng N, Kasznia-Brown J, Winant AJ, Lee EY, Sodhi KS. Tuberculosis revisted: classic imaging findings in childhood. Pediatr Radiol 2023; 53:1799-1828. [PMID: 37217783 PMCID: PMC10421797 DOI: 10.1007/s00247-023-05648-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023]
Abstract
Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.
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Affiliation(s)
- Nasreen Mahomed
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa.
| | - Tracy Kilborn
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Elsabe Jacoba Smit
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Winnie Chiu Wing Chu
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Catherine Yee Man Young
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nonceba Koranteng
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa
| | | | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Kushaljit Singh Sodhi
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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Decrease in osteoarticular tuberculosis in Spain between 1997 and 2018. REUMATOLOGIA CLINICA 2023; 19:45-48. [PMID: 35764501 DOI: 10.1016/j.reumae.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/09/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVE osteoarticular tuberculosis represents 2%-5% of the manifestations of tuberculosis. The objective was to calculate the incidence and describe the epidemiological characteristics of patients with osteoarticular tuberculosis who received hospital care in Spain between 1997-2018. METHODS A retrospective study was conducted of patients treated with osteoarticular tuberculosis in Spanish hospitals between 1997 and 2018, using the data from the Minimum Basic Data Set at hospital discharge, using the ICD-9-CM and ICD-10 codes. RESULTS 5710 patients with osteoarticular tuberculosis were detected over the 22 years in Spain. The mean annual incidence for the period was 6 cases per million inhabitants (95% CI 5.58-6.30). There was a significant difference between the mean annual incidence per million inhabitants of the first period (1997-2007) of 6.95 and that of the second (2008-2018) of 5.35 (p<.001). CONCLUSIONS The incidence of osteoarticular tuberculosis in Spain is low, has reduced over 22 years and predominates in men.
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Upadhyaya GK, Kumar A, Iyengar KP, Agarwal A, Jain VK. Current concepts in the diagnosis and management of tuberculosis of the elbow joint. J Clin Orthop Trauma 2021; 19:200-208. [PMID: 34150492 PMCID: PMC8185235 DOI: 10.1016/j.jcot.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022] Open
Abstract
Elbow is an uncommon joint to be affected by Mycobacterium tuberculosis infection. It is involved in approximately 1-5% of all cases with musculoskeletal tuberculosis (TB). Early diagnosis of TB of the elbow joint can be easily missed due to an indolent natural history, delay in presentation, and varied clinical features. Delay in diagnosis can lead to irreversible osteoarticular destruction and loss of joint function. Careful clinical assessment, adequate imaging, microbiological, and/or histopathological confirmation of Mycobacterium tuberculosis infection is essential for early diagnosis of TB of the elbow joint. Judicious and early administration of anti-tubercular therapy can lead to preservation of the joint and a satisfactory functional outcome. Surgical intervention may be needed in later stages of the disease to achieve control of the infection, correction of deformity, instability, and restoration of function.
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Affiliation(s)
- Gaurav Kumar Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, India
| | - Amit Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, India,All India Institute of Medical Sciences, Raebareli, UP, India
| | | | - Anil Agarwal
- Department of Pediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India,Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Science, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India.
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Karuppal R, Sreedhar S, Kasim A. Multifocal skeletal tuberculosis in nonimmunocompromised patient: Thumb infection as the tip of an iceberg. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2021. [DOI: 10.4103/jotr.jotr_30_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shah I, Dani S, Shetty NS, Mehta R, Nene A. Profile of osteoarticular tuberculosis in children. Indian J Tuberc 2020; 67:43-45. [PMID: 32192616 DOI: 10.1016/j.ijtb.2019.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine clinical profile of osteoarticular tuberculosis (TB) in children. METHODS Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included. RESULTS Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient. CONCLUSION Drug resistant osteoarticular TB is an emerging problem in children.
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Affiliation(s)
- I Shah
- Pediatric TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India.
| | - S Dani
- Pediatric TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India
| | - N S Shetty
- Pediatric TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India
| | - R Mehta
- Department of Pediatric Orthopedics, B.J. Wadia Hospital for Children, Mumbai, India
| | - A Nene
- Department of Pediatric Orthopedics, B.J. Wadia Hospital for Children, Mumbai, India
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Agarwal A. Paediatric osteoarticular tuberculosis: A review. J Clin Orthop Trauma 2020; 11:202-207. [PMID: 32099280 PMCID: PMC7026562 DOI: 10.1016/j.jcot.2020.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) is endemic in Indian subcontinent. The paediatric osteoarticular (OA) TB is frequently confused with suppurative etiology as both can have similar clinical, radiological and laboratory presentation. It has become a health hazard due to its association with immunosuppression diseases such as HIV, chronic renal and liver diseases and use of immunosuppressive drugs. Furthermore, there is much dilemma regarding the drug choice and duration of anti tubercular treatment among practicing clinicians. This mini review briefs the reader to the classical regional and atypical tubercular clinical presentations, imaging and laboratory investigations and management for bone and joint TB. METHODS The article details both common and atypical clinical tubercular presentations, the approach to diagnosis, drug treatment and surgical indications in paediatric OA TB. RESULTS OA TB in the paediatric age group is uncommon. Diagnosis is often delayed because of diseases' nonspecific symptoms, non-characteristic imaging findings and lack of awareness of the condition. Multidrug antitubercular chemotherapy remains the anchor sheet of tubercular treatment in children. Surgery is needed in select cases to obtain tissue, to ensure better joint movement, prevent deformities and restore neurological function. CONCLUSIONS TB can have varied presentation and therefore it is essential to keep tubercular infection in differential diagnosis while working up for any infective pathology. Conservative treatment produces good results in vast majority of cases. Surgery is reserved for select indications.
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Abstract
One million children develop tuberculosis disease each year, and 210,000 die from complications of tuberculosis. Childhood tuberculosis is very different from adult tuberculosis in epidemiology, clinical and radiographic presentation, and treatment. This review highlights the many unique features of childhood tuberculosis, with special emphasis on very young children and adolescents, who are most likely to develop disease after infection has occurred.
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Ramadani N, Dedushi K, Kabashi S, Mucaj S. Radiologic Diagnosis of Spondylodiscitis, Role of Magnetic Resonance. Acta Inform Med 2017; 25:54-57. [PMID: 28484299 PMCID: PMC5402372 DOI: 10.5455/aim.2017.25.54-57] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: Study aim is to report the Magnetic Resonance Imaging (MRI) features of acute and chronic spontaneous spondylodiscitis. Case report: 57 year old female, complaining of a fever and longstanding cervical pain worsened during physical therapy. Methods: MR images were acquired using superconductive magnet 1.5 T, with the following sequences: sagittal PD and T2 TSE, sagittal T1 SE, axial PD and T2 TSE (lumbar spine), axial T2 GRE (cervical spine). Axial and sagittal T1 SE after administration of (gadolinium DTPA). Examination was reviewed by three radiologists and compared to CT findings. Results: Patient reported cervical pain associated with fever and minimal weight loss. Blood tests were normal except hyperglycemia (DM tip II). X Ray: vertebral destruction localized at C-4 and C-5: NECT: destruction of the C-4/C-5 vertebral bodies (ventral part). MRI: Low signal of the bone marrow on T1l images, which enhanced after Gd-DTPA administration and became intermediate or high on T2 images. The steady high signal intensity of the disk on T2 images and enhancement on T1 images is typical for an acute inflammatory process. Bone Scintigrafi results: Bone changes suspicious for metastasis. Whole body CT results: apart from spine, no other significant changes. Conclusion: MRI is the most sensitive technique for the diagnosis of spondylodiscitis in the acute phase and comparable to CT regarding chronial stage of the disease. The present imagining essay os aimed at showing the main magnetic resonance imaging findings of tuberculous discitis.
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Affiliation(s)
- Naser Ramadani
- Faculty of Medicine, Pristine University, Pristine City, Kosovo.,National Institute of Public Health of Kosovo, Pristine City, Kosovo
| | - Kreshnike Dedushi
- Faculty of Medicine, Pristine University, Pristine City, Kosovo.,Department of Radiology, Diagnostic Centre, UCCK, Pristine City, Kosovo
| | - Serbeze Kabashi
- Faculty of Medicine, Pristine University, Pristine City, Kosovo.,Department of Radiology, Diagnostic Centre, UCCK, Pristine City, Kosovo
| | - Sefedin Mucaj
- Faculty of Medicine, Pristine University, Pristine City, Kosovo.,National Institute of Public Health of Kosovo, Pristine City, Kosovo
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Sarkar AS, Garg AK, Bandyopadhyay A, Kumar S, Pal S. Tuberculosis of Distal Radius Presenting as Cystic Lesion in a Nine-Month-Old Infant: A Rare Case Report. J Clin Diagn Res 2016; 10:RD06-RD07. [PMID: 27790537 DOI: 10.7860/jcdr/2016/19916.8564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/21/2016] [Indexed: 11/24/2022]
Abstract
Tuberculous osteomyelitis affecting long bones is a rare form of tuberculosis. Among infants born in endemic region, often it is difficult to diagnose owing to its subtle clinical features. Here, a case of tuberculous osteomyelitis affecting the distal radial metaphysis is reported, presenting as a cystic lesion in a nine-month-old male infant. Open biopsy with curettage was performed followed by filling of the cavity with synthetic bone substitute (beta tricalcium phosphate granules). The diagnosis was confirmed by histopathological examination and demonstration of acid fast bacilli. Further treatment with anti-tubercular drugs led to clinical and radiological improvement. This case report highlights the importance of keeping tuberculosis as a differential diagnosis while dealing with cases with similar presentation in an endemic region.
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Affiliation(s)
- Aniruddha Sinha Sarkar
- Junior Resident, Department of Orthopaedics, Nil Ratan Sircar Medical College and Hospital , Kolkata, West Bengal, India
| | - Anant Kumar Garg
- Assistant Professor, Department of Orthopaedics, Nil Ratan Sircar Medical College and Hospital , Kolkata, West Bengal, India
| | - Abhishek Bandyopadhyay
- Junior Resident, Department of Pathology, Nil Ratan Sircar Medical College and Hospital , Kolkata, West Bengal, India
| | - Sanjay Kumar
- Associate Professor, Department of Orthopaedics, Nil Ratan Sircar Medical College And Hospital , Kolkata, West Bengal, India
| | - Sumanta Pal
- Junior Resident, Department of Orthopaedics, Nil Ratan Sircar Medical College and Hospital , Kolkata, West Bengal, India
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Zhang L, Wang J, Feng X, Tao Y, Yang J, Zhang S, Cai J. Multifocal skeletal tuberculosis: A case report. Exp Ther Med 2016; 11:1288-1292. [PMID: 27073438 PMCID: PMC4812510 DOI: 10.3892/etm.2016.3032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 01/11/2016] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) of the musculoskeletal system is a rare clinical condition. Multifocal bone involvement is extremely rare and difficult to recognize. Thus, due to the diverse and atypical clinical manifestations of multifocal skeletal TB, the disease is easy to misdiagnose. In the present study, a rare case of atypical disseminated multifocal skeletal TB was reported, which exhibited uncommon findings in radiological images that were more suggestive of a hematological malignancy or metastatic disease. In conclusion, the diagnosis of this condition by conventional diagnostic methods is challenging. The importance of CT-guided needle biopsy and open biopsy in the diagnosis of skeletal TB was emphasized.
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Affiliation(s)
- Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Yuping Tao
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Jiandong Yang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Shenfei Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
| | - Jun Cai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu, Yangzhou, Jiangsu 225001, P.R. China
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de Araujo PSR, de Melo HRL, de Melo FL, Medeiros Z, Maciel MA, Florêncio R, Brandão E. Multifocal skeletal tuberculosis in an immunocompetent patient: a case report. BMC Infect Dis 2015; 15:235. [PMID: 26092386 PMCID: PMC4475287 DOI: 10.1186/s12879-015-0985-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/15/2015] [Indexed: 11/29/2022] Open
Abstract
Background The occurrence of multifocal skeletal involvement in immunocompetent patients is rare, even in countries where tuberculosis is endemic. Multifocal skeletal lesions may occur as a result of hematogenous dissemination from another primary focus such as cervical lymph nodes, lungs, tonsils or gastrointestinal tract. Case presentation We present a 59 year-old man with a history of intermittent and disabling pain in his left knee for 2 years. The patient in this case presented with lung infection with bilateral skeletal dissemination in the knees and femurs. Immunological examination for the HIV was negative. Conclusions Diagnosis of this condition is not always easy because of the disease’s insidious character, and it can be confused with other diseases such as osteoarthritis, especially in middle-aged individuals.
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Affiliation(s)
- Paulo Sérgio Ramos de Araujo
- Service of Infectious and Parasitic Diseases, Department of Tropical Medicine, Hospital de Clinicas, Federal University of Pernambuco, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil. .,Aggeu Magalhães Research Center, FIOCRUZ, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Heloisa Ramos Lacerda de Melo
- Service of Infectious and Parasitic Diseases, Department of Tropical Medicine, Hospital de Clinicas, Federal University of Pernambuco, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Fábio Lopes de Melo
- Aggeu Magalhães Research Center, FIOCRUZ, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Zulma Medeiros
- Aggeu Magalhães Research Center, FIOCRUZ, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Maria Amélia Maciel
- Service of Infectious and Parasitic Diseases, Department of Tropical Medicine, Hospital de Clinicas, Federal University of Pernambuco, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Renata Florêncio
- Service of Infectious and Parasitic Diseases, Department of Tropical Medicine, Hospital de Clinicas, Federal University of Pernambuco, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
| | - Eduardo Brandão
- Aggeu Magalhães Research Center, FIOCRUZ, Cidade Universitária, Av. Prof. Moraes Rego, 1235, Recife, PE, CEP: 50.670-901, Brazil.
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