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Thornton CR. The potential for rapid antigen testing for mucormycosis in the context of COVID-19. Expert Rev Mol Diagn 2024; 24:161-167. [PMID: 37405409 DOI: 10.1080/14737159.2023.2233906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/04/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections. AREAS COVERED The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed. EXPERT OPINION Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.
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Seshadri H, Saraf R, Barchha S. Radiological findings and endovascular management of internal carotid artery pseudoaneurysm in the setting of mucormycosis and COVID-19. BJR Case Rep 2024; 10:uaad006. [PMID: 38352267 PMCID: PMC10860580 DOI: 10.1093/bjrcr/uaad006] [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: 05/17/2022] [Revised: 07/21/2022] [Accepted: 11/14/2023] [Indexed: 02/16/2024] Open
Abstract
The coronavirus pandemic is now a public health emergency and has spread to nearly 206 countries across the globe. This novel disease has shaken the psycho-social, economic, and medical infrastructure of India. This has become even more challenging, considering the country's huge population. With the increase in the number of coronavirus disease (COVID) cases, our country has seen an unforeseen, unprecedented rise in a potential life and organ-threatening disease-mucormycosis. Mucormycosis is a deadly, extremely morbid, possibly life-threatening, and most feared complication of the coronavirus, caused by environmental molds belonging to the order Mucorales. Here, we report 2 cases of massive epistaxis due to internal carotid artery (ICA) pseudoaneurysm secondary to mucormycosis, post-COVID-19 pneumonia, which was managed by the endovascular route. To the best of our knowledge, there is very sparse literature available describing endovascular treatment of intracranial ICA pseudoaneurysm in a patient with COVID-induced mucormycosis.
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Affiliation(s)
| | - Rashmi Saraf
- Division of Interventional Neuroradiology, Department of Radiology, KEM Hospital, Mumbai 400012, India
| | - Satyam Barchha
- Department of Radiology, KEM Hospital, Mumbai 400012, India
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Senapathy G, Putta T, Sistla SK. Magnetic resonance imaging in COVID-19-associated acute invasive fungal rhinosinusitis - Diagnosis and beyond. J Clin Imaging Sci 2023; 13:23. [PMID: 37680251 PMCID: PMC10481822 DOI: 10.25259/jcis_46_2023] [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: 05/10/2023] [Accepted: 06/21/2023] [Indexed: 09/09/2023] Open
Abstract
Objectives The aim of the study was to evaluate the magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) at presentation and on follow-up imaging when patients receive treatment with systemic antifungal therapy and surgical debridement. Material and Methods This is a retrospective analysis of imaging data from a cohort of patients diagnosed with AIFRS during the second wave of COVID-19 in single tertiary referral hospital in South India between March 2021 and May 2021 (n = 68). Final diagnosis was made using a composite reference standard which included a combination of MRI findings, clinical presentation, nasal endoscopy and intraoperative findings, and laboratory proof of invasive fungal infection. Analysis included 62 patients with "Definite AIFRS" findings on MRI and another six patients with "Possible AIFRS" findings on MRI and laboratory proof of invasive fungal infection. Follow-up imaging was available in 41 patients. Results The most frequent MRI finding was T2 hypointensity in the sinonasal mucosa (94%) followed by mucosal necrosis/loss of contrast-enhancement (92.6%). Extrasinosal inflammation with or without necrosis in the pre-antral fat, retroantral fat, pterygopalatine fossa, and masticator space was seen in 91.1% of the cases. Extrasinosal spread was identified on MRI even when the computed tomography (CT) showed intact bone with normal extrasinosal density. Orbital involvement (72%) was in the form of contiguous spread from either the ethmoid or maxillary sinuses; the most frequent presentation being orbital cellulitis and necrosis, with some cases showing extension to the orbital apex (41%) and inflammation of the optic nerve (32%). A total of 22 patients showed involvement of the cavernous sinuses out of which 10 had sinus thrombosis and five patients had cavernous internal carotid artery involvement. Intracranial extension was seen both in the form of contiguous spread to the pachymeninges over the frontal and temporal lobes (25%) and intra-axial involvement in the form of cerebritis, abscesses, and infarcts (8.8%). Areas of blooming on SWI were noted within the areas of cerebritis and infarcts. Perineural spread of inflammation was seen along the mandibular nerves across foramen ovale in five patients and from the cisternal segment of trigeminal nerve to the root exit zone in pons in three patients. During follow-up, patients with disease progression showed involvement of the bones of skull base, osteomyelitis of the palate, alveolar process of maxilla, and zygoma. Persistent hyperenhancement in the post-operative bed after surgical debridement and resection was noted even in patients with stable disease. Conclusion Contrast-enhanced MRI must be performed in all patients with suspected AIFRS as non-contrast MRI fails to demonstrate tissue necrosis and CT fails to demonstrate extrasinosal disease across intact bony walls. Orbital apex, pterygopalatine fossa, and the cavernous sinuses form important pathways for disease spread to the skull base and intracranial compartment. While cerebritis, intracranial abscesses, and infarcts can be seen early in the disease due to the angioinvasive nature, perineural spread and skull base infiltration are seen 3-4 weeks after disease onset. Exaggerated soft-tissue enhancement in the post-operative bed after debridement can be a normal finding and must not be interpreted as disease progression.
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Affiliation(s)
- Gayatri Senapathy
- Department of Radiology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
| | - Tharani Putta
- Department of Radiology, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
| | - Srinivas Kishore Sistla
- Department of ENT, Asian Institute of Gastroenterology Hospitals, Hyderabad, Telangana, India
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Kurysheva NI, Kapkova SG, Naumova VI, Smolev DM, Lishchuk SV, Nekrasova EY, Kim VE. [Late diagnosis of rhinocerebral mucormycosis in patients with COVID-19 (case studies)]. Vestn Oftalmol 2023; 139:110-121. [PMID: 38235637 DOI: 10.17116/oftalma2023139061110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
From the beginning of the COVID-19 pandemic, the incidence of secondary infections (both bacterial and fungal) has increased due to immune suppression associated with the use of corticosteroids or broad-spectrum antibiotics as a part of COVID-19 treatment protocol, which may exacerbate a pre-existing fungal disease or cause a new infection. Ophthalmologists are often involved in taking medical and surgical decisions in these complex cases. In this regard, a strong clinical suspicion should be applied to possible secondary fungal infections in COVID-19. Their early diagnosis and treatment may reduce mortality due to COVID-19 associated rhinocerebral mucormycosis (ROCM). This article describes two clinical cases of late detection of ROCM with two different scenarios, and compare the features of these cases with the literature data.
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Affiliation(s)
- N I Kurysheva
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
- Postgraduate Education Academy, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of Federal Medical Biological Agency, Moscow, Russia
| | - S G Kapkova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
- Postgraduate Education Academy, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of Federal Medical Biological Agency, Moscow, Russia
| | - V I Naumova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - D M Smolev
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - S V Lishchuk
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - E Yu Nekrasova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - V E Kim
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
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Samimiardestani S, Irani S, Hasibi M, Seyedahadi M, Bastaninejad S, Firouzifar M, Mohammadi Ardehali M, Berijani S, Erfanian R, Kazemi MA, Etemadi-Aleagha A, Rahimi A, Karimi Yarandi K, Ahadi S. Distinguishing Characteristics of COVID-19-Associated Mucormycosis; a Case Series. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e66. [PMID: 36381973 PMCID: PMC9637258 DOI: 10.22037/aaem.v10i1.1644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Since the emergence of COVID-19 pandemic, several articles have reported the co-existence of mucormycosis and COVID-19. This study aimed to distinguish the characteristics of COVID-19-associated rhinocerebral mucormycosis. METHODS In this case series, 18 patients with COVID-19-associated rhinocerebral mucormycosis and unique clinical manifestations and outcomes, who were referred to Amiralam Hospital, a tertiary otorhinolaryngology center, Tehran, Iran, during the COVID-19 era, were reported. RESULTS Eighteen patients with the mean age of 62.0 ± 11.6 (range: 42 - 83) years were studied (50% males). The mean time interval between diagnosis of COVID-19 and first manifestation of mucormycosis was 15.5 ± 9.7 days. The most common presenting symptom was facial paresthesia (72.2%). Fifty percent of patients developed frozen eye. Palatal necrosis was seen in 7 cases (38.8%). Remarkably, facial paralysis was observed in 5 (27.7%) patients. Another notable clinical picture was cavernous sinus thrombosis, seen in 7 patients. We also had two cases of carotid artery occlusion. Three patients, unfortunately, passed away. CONCLUSION Rhinocerebral mucormycosis is one of the most important complications of COVID-19 patients, especially those with underlying diseases. It seems that the key to proper management of mucormycosis is early diagnosis and timely intervention, which could give a patient a chance to live more.
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Affiliation(s)
- Seyedhadi Samimiardestani
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Irani
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran. ,Corresponding Author: Shirin Irani; Amiralam Hospital, North Sa’di Street, Enghelab Street, Tehran, Iran. Fax Number: +98 2166343177, , Cell phone: +98 912 4182775
| | - Mehrdad Hasibi
- Infectious Disease Department, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maral Seyedahadi
- Neurology Department, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Bastaninejad
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Firouzifar
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sina Berijani
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Erfanian
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Kazemi
- Department of Radiology, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshar Etemadi-Aleagha
- Department of Anesthesiology, Amir-Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Rahimi
- Department of Ophthalmology, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | | | - Samira Ahadi
- Otorhinolaryngology Research Center, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Kaushik KS, Ananthasivan R, Acharya UV, Rawat S, Patil UD, Shankar B, Jose A. Spectrum of intracranial complications of rhino-orbito-cerebral mucormycosis - resurgence in the era of COVID-19 pandemic: a pictorial essay. Emerg Radiol 2021; 28:1097-1106. [PMID: 34605991 PMCID: PMC8488318 DOI: 10.1007/s10140-021-01987-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/10/2021] [Indexed: 11/26/2022]
Abstract
Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM.
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Affiliation(s)
- Kavya S Kaushik
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
| | - Rupa Ananthasivan
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India.
| | - Ullas V Acharya
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
| | - Sudarshan Rawat
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
| | - Uday Damodar Patil
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
| | - Balasubramanyam Shankar
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
| | - Abin Jose
- Department of Radiology, Manipal Hospitals, 98, HAL Old Airport Road, Kodihalli, Bengaluru, 560017, India
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Little JS, Cheng MP, Hsu L, Corrales CE, Marty FM. Invasive Fungal Carotiditis: A Rare Manifestation of Cranial Invasive Fungal Disease: Case Series and Systematic Review of the Literature. Open Forum Infect Dis 2019; 6:ofz392. [PMID: 31660355 PMCID: PMC6790399 DOI: 10.1093/ofid/ofz392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/02/2019] [Indexed: 12/17/2022] Open
Abstract
Background Rhinosinusitis, malignant otitis externa, and skull base osteomyelitis represent a spectrum of cranial invasive fungal disease (IFD). These syndromes have distinct characteristics, yet they may progress to involve similar structures, resulting in inflammation and invasion of the adjacent internal carotid artery (ICA). Invasive fungal carotiditis can have devastating consequences, including cerebral infarction, subarachnoid hemorrhage, and death. Methods We retrospectively studied all patients diagnosed with cranial IFD and carotid involvement at our institution from 2003 to 2018. We also searched Medline/PubMed for reports of Aspergillus or Mucorales cranial infections with ICA involvement. All cases with mycologic evidence of cranial IFD and radiographic or pathologic evidence of ICA involvement were included. Results We identified 78 cases of invasive fungal carotiditis between 1958 and 2018, including 4 cases at our own institution. Forty-one were caused by Aspergillus and 37 by Mucorales species. Presenting symptoms included vision changes (73%), cranial nerve palsy (69%), and headache (42%). Carotid events included occlusion, aneurysm formation, and vessel rupture. Cerebral infarcts occurred in 50% of cases. Mortality at 6 weeks, 12 weeks, and 2 years was 27%, 41%, and 71% respectively. The median time from symptom onset to death was 150 days for cases due to Aspergillus and 51 days for cases due to Mucorales species. Conclusions Invasive fungal carotiditis is a rare but morbid manifestation of cranial IFD. Early suspicion of IFD and administration of antifungal treatment, vascular imaging, and endovascular interventions should be considered to reduce the high mortality of this disease.
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Affiliation(s)
- Jessica S Little
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew P Cheng
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massaschusetts, USA
| | - Liangge Hsu
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Neuroradiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Francisco M Marty
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massaschusetts, USA
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Kashyap S, Bernstein J, Ghanchi H, Bowen I, Cortez V. Diagnosis of Rhinocerebral Mucormycosis by Treatment of Cavernous Right Internal Carotid Artery Occlusion With Mechanical Thrombectomy: Special Case Presentation and Literature Review. Front Neurol 2019; 10:264. [PMID: 30972005 PMCID: PMC6443639 DOI: 10.3389/fneur.2019.00264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/27/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Mucormycosis is a rapidly progressive, angioinvasive fungal infection that has a predilection for the paranasal sinuses and adjacent mucosa. Rhinocerebral mucormycosis (RCM) is the most common form and is known to invade the skull base and its associated blood vessels—leading to mycotic aneurysms, ischemic infarcts, and intracerebral hemorrhage. There are documented cases of mechanical thrombectomy in ischemic stroke due to RCM, however, there are no known cases that were diagnosed primarily by histological and pathological analysis of the embolus. We present a case of treatment of large vessel occlusion that led to the diagnosis and treatment of RCM. Case Presentation: A 21 year-old male inmate with history of type 1 diabetes presented with generalized weakness, abdominal pain, right eye blindness, and ophthalmoplegia after an assault in prison. He underwent treatment for diabetic ketoacidosis, but subsequently developed left hemiplegia and was found to have complete occlusion of his right internal carotid artery. He underwent successful mechanical thrombectomy and pathological analysis of the embolus revealed a diagnosis of mucormycosis. He completed a course of amphotericin B, micafungin, and posaconazole. With the aid of acute rehabilitation he achieved a modified Rankin score of 2. Discussion: We review the pathogenesis, diagnosis, and treatment of RCM. A comprehensive multidisciplinary approach is critical in the management of this often-fatal disease. Early diagnosis and treatment are essential in RCM as delaying treatment by more than 6 days significantly increases mortality. Treatment includes surgical debridement and intravenous antifungal therapy (amphotericin B + micafungin or caspofungin) for a minimum of 6–8 weeks.
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Affiliation(s)
- Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Moreno Valley, CA, United States.,Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, United States.,Redlands Community Hospital, Redlands, CA, United States
| | - Jacob Bernstein
- Department of Neurosurgery, Riverside University Health System, Moreno Valley, CA, United States.,Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, United States.,Redlands Community Hospital, Redlands, CA, United States
| | - Hammad Ghanchi
- Department of Neurosurgery, Riverside University Health System, Moreno Valley, CA, United States.,Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, United States.,Redlands Community Hospital, Redlands, CA, United States
| | - Ira Bowen
- Department of Neurosurgery, Riverside University Health System, Moreno Valley, CA, United States.,Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, United States.,Redlands Community Hospital, Redlands, CA, United States
| | - Vladimir Cortez
- Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, CA, United States.,Redlands Community Hospital, Redlands, CA, United States
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