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Nguyen CG, Wikner EE, Gallagher TQ, Birsch LA, Darrow DH. Diagnosis and Management of Riga-Fede Disease: A Case Series. Laryngoscope 2024. [PMID: 38837419 DOI: 10.1002/lary.31547] [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: 04/13/2024] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
In this case series, we present four unique cases of Riga-Fede disease (RFD), a rare disorder characterized by mucosal trauma as a result of repetitive tongue protrusion against the incisors, leading to the development of a large oral mass/ulceration. Due to the rapid development and growth of these lesions mimicking malignancy, it is important for the general and pediatric otolaryngologist to correctly diagnose and treat this benign disorder. This series highlights the variable clinical presentations, along with comorbidities of RFD, as well as the importance of interdisciplinary care between the pediatric otolaryngologist and pediatric dentist in its management. Laryngoscope, 2024.
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Affiliation(s)
| | - Emily E Wikner
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Department of Otolaryngology-Head & Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Thomas Q Gallagher
- Department of Otolaryngology-Head & Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital of The King's Daughters, Norfolk, Virginia, U.S.A
| | - Laurie A Birsch
- Staff Pediatric Dentist, Children's Hospital of The King's Daughters, Norfolk, Virginia, U.S.A
| | - David H Darrow
- Department of Otolaryngology-Head & Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital of The King's Daughters, Norfolk, Virginia, U.S.A
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Axelrod B, Reddy R, Steinberg M. An Unusual Clinical Presentation of Traumatic Ulcerative Granuloma With Stromal Eosinophilia. J Oral Maxillofac Surg 2024:S0278-2391(24)00337-9. [PMID: 38885935 DOI: 10.1016/j.joms.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/20/2024]
Abstract
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a reactive and chronic ulcerative lesion that is most frequently found on the tongue. It appears as a large yellowish ulcer with elevated margins and central induration. TUGSEs exhibit a characteristic pattern of regression often spontaneously, following incisional biopsy, or after removal of the potential traumatic trigger. Herein, we present an unusual case of a TUGSE on the anterior maxillary gingiva of a 70-year-old male that regressed following incisional biopsy. Histopathologic evaluation revealed fragments of squamous mucosa and submucosal tissue with large atypical cells mixed with small lymphocytes, abundant eosinophils, and focal clusters of plasma cells. Immunohistochemistry was performed and the large, atypical cells were positive for CD3, CD4, CD5, and CD30 and negative for CD1a, CD8, CD20, CD56, CD117, ALK1, Langerin, and EBER ISH. To our knowledge, this is the first case of TUGSE reported in the anterior maxilla.
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Affiliation(s)
| | - Rekha Reddy
- Clinical Assistant Professor, Stony Brook School of Dental Medicine, Department of Oral and Maxillofacial Surgery, Department of Pathology, Stony Brook, NY
| | - Mitchell Steinberg
- Clinical Assistant Professor, Stony Brook School of Dental Medicine, Department of Oral and Maxillofacial Surgery, Stony Brook, NY
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Rosa DE, Hapid MH, Hidayat W. Non-Healing Chronic Traumatic Ulcer, an Entity That Can Resemble Other Chronic Ulcers. Int Med Case Rep J 2023; 16:585-590. [PMID: 37779825 PMCID: PMC10540854 DOI: 10.2147/imcrj.s421748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Traumatic ulcer commonly occurs in the oral cavity, resulting in the loss of the entire epithelium. Traumatic ulcers often appear to mimic other lesions of the oral mucosa but the causative factors and other characteristic features rule out the differential diagnosis. It may have a similar appearance to some oral ulcer lesions such as traumatic ulcer granuloma with stromal eosinophilia (TUGSE) and oral squamous cell carcinoma (OSCC). Objective To identify traumatic ulcers from other chronic lesions such as TUGSE and OSCC. Case First case, a 63-year-old female complained of pain on the right side of the tongue for 4 months. Intraoral examination showed a painful single ulcer, mild keratosis white halo, and induration on the right lateral of the tongue. The second case, a 38-year-old male complained of pain on the left side of the tongue for 2 months. Intraoral examination showed a painful single ulcer, mild keratosis white halo, and induration on the left lateral of the tongue. In both cases, there were some retained roots where the ulcer was located, and due to its contact with lateral of the tongue and the appearance of the lesion, we got a provisional diagnosis of traumatic ulcer. Case Management These ulcers had a visual appearance similar to OSCC and TUGSE, so eliminating etiological factors and a comprehensive treatment plan were needed. We planned to extract teeth close to the lesion that was suspected to be the etiology of traumatic ulcer. We also prescribed 0.1% triamcinolone acetonide in orabase to improve healing. One week later, the ulcer in both patients had healed. Conclusion Recognition of traumatic ulcer characteristics is crucial in eliminating local factors to get rid of any differential diagnosis.
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Affiliation(s)
- Desi Elvhira Rosa
- Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - M Hasan Hapid
- Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Wahyu Hidayat
- Oral Medicine Department, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
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Ouaabbou H, Bahbah S, Chbicheb S. Traumatic ulcer of the tongue mimicking a malignant lesion: Case report. Int J Surg Case Rep 2023; 109:108460. [PMID: 37473621 PMCID: PMC10372728 DOI: 10.1016/j.ijscr.2023.108460] [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: 05/22/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The most prevalent oral ulcers are those caused by trauma, and their etiopathogenesis has been frequently obvious. Yet, oral ulcers can be misdiagnosed and managed incorrectly. CASE PRESENTATION A 25-year-old patient presented to our service with a painful lesion on the right lateral border of the tongue that had evolved for one week. A possible traumatic factor was identified. The ulcer completely recovered once the trauma's cause was removed. An accurate diagnosis was achieved by combining a precise physical examination with clinical follow-up. CLINICAL DISCUSSION Single oral ulcers have various clinical presentations that can be confusing. Some of them may mimic oral squamous cell carcinoma (OSCC), especially when accompanied by any induration. Determining the cause of oral ulceration requires a careful medical history and a clinical examination with inspection and palpation, which may be combined with other accessory investigations if necessary. CONCLUSION This clinical case reinforces the importance of investigating local causes before moving on to systemic ones. We present differential diagnosis and management algorithm of single oral ulcers.
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Affiliation(s)
- Hajar Ouaabbou
- Department of Oral Surgery, Faculty of Dentistry, Mohammed V University in Rabat, Morocco.
| | - Soukayna Bahbah
- Department of Oral Surgery, Faculty of Dentistry, Mohammed V University in Rabat, Morocco
| | - Saliha Chbicheb
- Department of Oral Surgery, Faculty of Dentistry, Mohammed V University in Rabat, Morocco
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Kacar S, Duprez T, Gheysens O, Schmitz S, Van Eeckhout P. Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE): Case report of a 63-year-old male patient with a rare self-healing oral mucosal lesion. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023:101514. [PMID: 37207961 DOI: 10.1016/j.jormas.2023.101514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/21/2023]
Abstract
Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE)/Riga Fede disease is a rare mucosal and submucosal benign reactive inflammatory process, usually involving the tongue. Trauma is believed to be a major factor amongst the multiple pathogenic mechanisms that have been hypothesized in TUGSE. The lesion presents as an isolated indurated or even ulcerated mass, which may mimic, clinically a squamous cell carcinoma (SCC). We herein report a case of TUGSE in a 63-year-old male referred by his treating physician for high suspicion of tongue malignancy. Histopathological examination confirmed the diagnosis of TUGSE, without any evidence of a neoplasic, infectious or hematologic process. TUGSE occurs in patients with an age range of 41-60 years. Sufficiently deep biopsies with comprehensive immunohistochemical and molecular analyses are mandatory to confirm the benign nature of the lesion and to, definitely, rule out malignancy. This report highlights the need for adequate histological differential diagnosis to avoid inappropriate heavy treatments in a benign condition.
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Affiliation(s)
- Serife Kacar
- Department of Pathology, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium
| | - Thierry Duprez
- Department of Medical Imaging, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium
| | - Sandra Schmitz
- Department of Ear-Nose-Throat, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium
| | - Pascal Van Eeckhout
- Department of Pathology, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium.
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Siregar FD, Hidayat W. The Role of Vitamin D on the Wound Healing Process: A Case Series. Int Med Case Rep J 2023; 16:227-232. [PMID: 37035834 PMCID: PMC10075270 DOI: 10.2147/imcrj.s402005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction Vitamin D is an essential steroid hormone that consists of two forms, namely vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol), which can be obtained from exposure to sunlight, synthesis of vitamin D in the skin, food and dietary supplements. Prevalence of vitamin D deficiency in several countries including Indonesia is still high, while the role of vitamin D is very important including accelerating the wound healing process, increasing the immune system, anti-inflammatory, and anti-bacterial. Purpose This case report aims to find out the role of vitamin D in the wound-healing process in the oral mucosa. Case Reports Two men went to the Oral Disease Clinic with complaints of canker sores on the oral mucosa for more than a month accompanied by pain. Intra-oral condition in the first patient showed multiple ulcers with yellowish white base surrounded by erythematous areas, well-defined, irregular with a size of 1.5 × 1 cm and 1 × 0.5 cm on the right and left buccal mucosa, while intra-oral in the second patient, a single ulcer with a base was found yellowish colour surrounded by erythematous area, oval measuring 3x1 cm, clearly demarcated with induration. Results Laboratory examination of vitamin D in both patients showed decreased levels of vitamin D with values of 28.7 and 9.8 ng/mL. Conclusion Vitamin D supplementation has shown effectiveness in wound-healing processes in the oral mucosa.
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Affiliation(s)
- Fitri Dona Siregar
- Speciality Program of Oral Medicine, Faculty of Dentistry Universitas Padjadjaran, Bandung, West Java, Indonesia
- Correspondence: Fitri Dona Siregar, Faculty of Dentistry Universitas Padjadjaran, Jl. Sekeloa Selatan I No. 1, Bandung, West Java, 40132, Indonesia, Email
| | - Wahyu Hidayat
- Department of Oral Medicine, Faculty of Dentistry Universitas Padjadjaran, Bandung, West Java, Indonesia
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Arbune M, Padurariu-Covit MD, Niculet E, Chiscop I, Arbune AA, Tatu AL. Ulceration and a White Lesion of the Tongue in a Male HIV Positive Patient: A Journey on the Avenue of Differential Diagnoses in Search of a Solution. Life (Basel) 2023; 13:life13040901. [PMID: 37109430 PMCID: PMC10147043 DOI: 10.3390/life13040901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023] Open
Abstract
Oral lesions are early indicator of immunosuppression, leading to HIV new diagnoses. The type of oral lesions can reveal opportunistic diseases that are correlated with the severity of immune depletion. Highly active antiretroviral therapy decreases the incidence of opportunistic oral infections, whereas a large variety of lesions are frequently experienced in people with HIV. Overlapping pathogenic mechanisms and multiple contributing etiologies are related to unusual, atypical oral lesions that are challenging in the clinical practice. We present a rare case of eosinophilic granuloma of the tongue in an older male HIV patient with severe immunosuppression due to the failure of antiretroviral treatment. Differential diagnoses considered squamous carcinoma, lymphoma, viral, fungal or bacterial infections and autoimmune disorders, as well as the influence of HIV immune disfunctions or the influence of cannabidiol use. The histopathologic and immunohistochemistry examination clarified the inflammatory reactive benign substrate of the lesion, although future survey of the oral lesions is essential.
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Affiliation(s)
- Manuela Arbune
- Clinical Medical Department, Medicine and Pharmacy Faculty, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.A.); (A.-L.T.)
- Infectious Diseases Clinic Department I, Infectious Diseases Clinic Hospital “Sf. Cuv. Parascheva”, 800179 Galati, Romania
- Multidisciplinary Integrated Center of Dermatological Interface Research (MIC-DIR), “Dunarea de Jos” University, 800010 Galati, Romania;
| | - Monica-Daniela Padurariu-Covit
- The School for Doctoral Studies in Biomedical Sciences, “Dunarea de Jos” University of Galați, 800008 Galati, Romania
- Hematology Department, Emergency County Hospital “Sf. Apostol Andrei”, 800578 Galati, Romania
- Correspondence: (M.-D.P.-C.); (E.N.)
| | - Elena Niculet
- Multidisciplinary Integrated Center of Dermatological Interface Research (MIC-DIR), “Dunarea de Jos” University, 800010 Galati, Romania;
- The School for Doctoral Studies in Biomedical Sciences, “Dunarea de Jos” University of Galați, 800008 Galati, Romania
- Pathology Department, Emergency County Hospital “Sf. Apostol Andrei”, 800578 Galati, Romania
- Correspondence: (M.-D.P.-C.); (E.N.)
| | - Iulia Chiscop
- Oral and Maxillofacial Surgery Department, Emergency County Hospital “Sf. Apostol Andrei”, 800578 Galati, Romania;
- Clinical Surgery Department, Medicine and Pharmacy Faculty, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Anca-Adriana Arbune
- Multidisciplinary Integrated Center of Dermatological Interface Research (MIC-DIR), “Dunarea de Jos” University, 800010 Galati, Romania;
- Neurology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alin-Laurențiu Tatu
- Clinical Medical Department, Medicine and Pharmacy Faculty, “Dunarea de Jos” University of Galati, 800008 Galati, Romania; (M.A.); (A.-L.T.)
- Multidisciplinary Integrated Center of Dermatological Interface Research (MIC-DIR), “Dunarea de Jos” University, 800010 Galati, Romania;
- Dermato-Venerology Clinic Department, Infectious Diseases Clinic Hospital “Sf. Cuv. Parascheva”, 800179 Galati, Romania
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Hamie L, Hamie M, Kurban M, Abbas O. Eosinophilic ulcer of the oral mucosa: An update on clinicopathologic features, pathogenesis, and management. Int J Dermatol 2021; 61:1359-1363. [PMID: 34812492 DOI: 10.1111/ijd.15986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/26/2021] [Accepted: 11/06/2021] [Indexed: 11/29/2022]
Abstract
Eosinophilic ulcer of the oral mucosa is a benign, reactive, self-limited lesion. Its pathogenesis is unclear, and it clinically manifests as a punched-out ulcer with surrounding indurated border, raising suspicion for a possible malignancy. On histology, an acute and chronic dense inflammatory infiltrate can be appreciated, which can extend to the deep underlying tissue (including skeletal muscle). Eosinophils are especially conspicuous on hematoxylin and eosin staining and might play an important role in the development of the ulcer. Removal of possible triggers followed by monitoring and possible biopsy are among the initial recommendations. Most lesions heal spontaneously without the need for intervention. This review aims at assisting dermatologists to easily recognize this entity, avoiding unnecessary interventions and apprehension.
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Affiliation(s)
- Lamiaa Hamie
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maria Hamie
- Dentistry, Beirut Arab University, Beirut, Lebanon
| | - Mazen Kurban
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon.,Division of Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Ossama Abbas
- Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
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Nguyen T, Yaghsezian A, Lin YL, Klokkevold P. An unusual case of cluster of differentiation 30-positive T-cell lymphoproliferative disorder manifesting as mandibular gingival ulceration: A case report. J Am Dent Assoc 2021; 153:175-182. [PMID: 34756592 DOI: 10.1016/j.adaj.2021.07.015] [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: 05/03/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Primary cutaneous cluster of differentiation 30-positive (CD30+) T-cell lymphoproliferative disorders are the second most common type of skin T-cell lymphoma. The lesions exhibit an indolent course, with a morphology resembling high-grade T-cell lymphoma. CASE DESCRIPTION A 67-year-old healthy man sought treatment for a large nonhealing ulcer on the buccal gingiva of the mandibular right premolars. He reported a history of recurrent cutaneous lesions, for which he was seen 1 year earlier at a hospital. Results of incisional biopsy showed a dense lymphoid cell infiltrate composed of atypical CD30+ T-cells intermixed with eosinophils. The diagnosis was updated to CD30+ T-cell lymphoproliferative disorder, which was similar to the cutaneous lesion diagnosis. The lesion area healed completely, and there were no signs of recurrence at 18-month follow-up. PRACTICAL IMPLICATIONS Oral CD30+ T-cell lymphoproliferative disorder has a favorable outcome, but it is commonly misdiagnosed. Biopsy is crucial and should be combined with clinical examination to avoid chemotherapeutic treatments intended for high-grade lymphoma.
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Lakkam BD, Astekar M, Alam S, Saleem A. Traumatic ulcerative granuloma with stromal eosinophilia: A puzzle. J Oral Maxillofac Pathol 2021; 25:S42-S45. [PMID: 34083969 PMCID: PMC8123250 DOI: 10.4103/jomfp.jomfp_321_20] [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: 07/30/2020] [Accepted: 01/29/2021] [Indexed: 11/09/2022] Open
Abstract
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an ulcerative condition of the oral mucosa amid a chronic course and delayed healing. It is a reactive lesion that usually affects the tongue. TUGSE is a rare mucosal lesion to aid as an ulcer or an indurated submucosal mass and might cause diagnostic problems as it mimics a traumatic or neoplastic ulcer. However, chronic irritation from traumatic agents is well thought out to be a major initiating aspect. Histopathologically, it is categorized by an eosinophilic inflammatory infiltrate penetrating into the underlying muscle. It is significant to make out this mucosal lesion as it mimics malignant ulcers; the condition tends to resolve on its own. Thus, attentiveness of this entity is imperative to emphasize the accurate diagnosis of indurated ulcerated lesions and convey suitable and effective treatment. The present case highlights the clinical aspects, etiopathogenesis and histopathology of this unusual lesion.
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Affiliation(s)
- Bhagirathi D Lakkam
- Department of Oral Pathology and Microbiology, Sri Sai Krupa Dental Clinic, Gulburga, Karnataka, India
| | - Madhusudan Astekar
- Department of Oral Pathology and Microbiology, Bareilly International University, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
| | - Shakir Alam
- Department of Oral Pathology and Microbiology, Bareilly International University, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
| | - Adeeba Saleem
- Department of Public Health Dentistry, Bareilly International University, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
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Vargo RJ, Qureshi A. A painful ulceration of the buccal mucosa. J Am Dent Assoc 2020; 152:866-871. [PMID: 33158494 DOI: 10.1016/j.adaj.2020.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 11/26/2022]
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Hannan TA, Umer M, Syed L, Anis‐Alavi MA. A case report of traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) in a 21-year-old. Clin Case Rep 2020; 8:2214-2216. [PMID: 33235761 PMCID: PMC7669417 DOI: 10.1002/ccr3.3188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/31/2020] [Accepted: 06/07/2020] [Indexed: 11/10/2022] Open
Abstract
We present an unusual case of a persistent solitary left palatoglossal ulcer with no history of trauma or associated risk factors. A TUGSE lesion, which mimics that of malignancy, must always be noted as a differential even in risk factor absence.
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Affiliation(s)
| | - Muhammed Umer
- Barts and The London School of Medicine and DentistryLondonUK
| | - Labib Syed
- Barts and The London School of Medicine and DentistryLondonUK
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