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Müller CSL, Vogt T, Becker SL. Kikuchi-Fujimoto Disease Triggered by Systemic Lupus Erythematosus and Mycoplasma pneumoniae Infection-A Report of a Case and a Review of the Literature. Am J Dermatopathol 2021; 43:202-208. [PMID: 32809980 DOI: 10.1097/dad.0000000000001764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ABSTRACT Kikuchi-Fujimoto disease (KFD) is a necrotizing histiocytic lymphadenitis that was described for the first time in 1972 in Japan. Its etiology is still not fully understood. It has been reported in association with many different agents, diseases, and triggering factors without any conclusive result. To the best of our knowledge, we report for the first time a case of KFD with systemic lupus erythematosus in a child in association with a polymerase chain reaction (PCR)-positive throat swab for Mycoplasma pneumoniae. Although difficult to prove, the acute M. pneumoniae infection might have served as a triggering event for the development of KFD in our case. We encourage further studies to investigate a potential relationship between KFD and M. pneumoniae, which should also use PCR-based testing for this pathogen in patients with KFD.
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Affiliation(s)
- Cornelia S L Müller
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg/Saar, Germany
- Swiss Tropical and Public Health Institute, Basel, Switzerland; and
- University of Basel, Basel, Switzerland
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Dalugama C, Gawarammana IB. Fever with lymphadenopathy - Kikuchi Fujimoto disease, a great masquerader: a case report. J Med Case Rep 2017; 11:349. [PMID: 29246252 PMCID: PMC5732422 DOI: 10.1186/s13256-017-1521-y] [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] [Received: 09/05/2017] [Accepted: 11/20/2017] [Indexed: 12/05/2022] Open
Abstract
Background Kikuchi Fujimoto disease is an uncommon benign condition of necrotizing histiocytic lymphadenitis commonly seen in East Asian and Japanese populations. It commonly presents with fever, cervical lymphadenopathy, and elevated inflammatory markers. Diagnosis of Kikuchi Fujimoto disease is based on histopathological studies of the involved lymph nodes. The presentation of Kikuchi Fujimoto disease can mimic many sinister conditions including lymphoma. Treatment is mainly supportive provided that accurate diagnosis is made and sinister conditions like lymphoma ruled out. Case presentation We report the case of an 18-year-old Sri Lankan Moor woman who presented with fever and cervical lymphadenopathy for 1 month. She had elevated inflammatory markers with high lactate dehydrogenase and ferritin levels. She had an extensive work-up including an excision biopsy of an involved lymph node and bone marrow biopsy. Finally, a diagnosis of Kikuchi Fujimoto disease was based on histopathology of the lymph node and negative bone marrow biopsy. Conclusions Although Kikuchi Fujimoto disease is a self-limiting condition, it is a great masquerader which mimics the clinical features of many sinister conditions including tuberculosis, lymphoma, and adult-onset Still’s disease. Early recognition of the disease is of crucial importance in minimizing potentially harmful and unnecessary evaluations and treatments.
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Affiliation(s)
- Chamara Dalugama
- Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
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Mathew LM, Kapila R, Schwartz RA. Kikuchi-Fujimoto disease: a diagnostic dilemma. Int J Dermatol 2016; 55:1069-75. [PMID: 27207311 DOI: 10.1111/ijd.13314] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/08/2015] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
Kikuchi-Fujimoto disease is a benign, self-limiting condition characterized by lymphadenopathy and fever. Its diagnosis can be challenging, as the disease must be differentiated from lymphoma and systemic lupus erythematosus. Patients can present with nonspecific cutaneous lesions. Adequate clinical and histopathologic correlation can aid in the timely diagnosis of Kikuchi's disease, thus preventing the use of unnecessary diagnostic procedures and inappropriate treatments.
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Affiliation(s)
- Laju M Mathew
- Dermatology, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA
| | - Rajendra Kapila
- Infectious Diseases, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA.,Medicine, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA
| | - Robert A Schwartz
- Dermatology, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA. .,Medicine, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA. .,Pathology, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA. .,Pediatrics, Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA. .,Rutgers New Jersey Medical School and Rutgers University School of Public Affairs and Administration, Newark, NJ, USA.
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Ojeda Lewis E, Vásquez Paz H. Kikuchi-Fujimoto disease: pediatric case report. Medwave 2015; 15:e6270. [DOI: 10.5867/medwave.2015.08.6270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/07/2015] [Indexed: 11/27/2022] Open
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Epstein-Barr virus: dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders. J Am Acad Dermatol 2015; 72:1-19; quiz 19-20. [PMID: 25497917 DOI: 10.1016/j.jaad.2014.07.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/23/2014] [Accepted: 07/16/2014] [Indexed: 12/22/2022]
Abstract
Epstein-Barr virus (EBV) is a ubiquitous virus that has been implicated in a wide range of human diseases, many of which have mucocutaneous manifestations. As a member of the herpesviridae family, EBV causes lifelong infection by establishing latency in B lymphocytes. An intact immune response is critical in preventing progression of EBV disease, and the clinical manifestations of infection are dependent on the intricate relationship between virus and host immune system. This review provides a comprehensive overview of the epidemiology, pathophysiology, and diagnostic testing in EBV infection. In part I of this continuing medical education article, the mucocutaneous manifestations of EBV infection are reviewed with an emphasis on pathophysiology and management.
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Chong Y, Kang CS. Causative agents of Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis): a meta-analysis. Int J Pediatr Otorhinolaryngol 2014; 78:1890-7. [PMID: 25200851 DOI: 10.1016/j.ijporl.2014.08.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Kikuchi-Fujimoto disease (KFD) is a self-limiting disorder characterized by histiocytic necrotizing lymphadenitis in the cervical lymph nodes of young women. Although an infectious etiology has been postulated, a definitive causative agent has not been identified. The few dozens of published studies are limited by small sample size and poorly structured study designs. The purpose of this study is to evaluate the association of each infectious agent to KFD that has been studied. METHODS We performed metaanalysis using major electronic database (MEDLINE (PubMed), Cochrane library, Embase, Web of Science, NML gateway, LILACS, and Google Scholar). Cross-sectional studies on the positivity of each agent in clinicopathologically diagnosed KFD and normal controls by polymerase chain reaction (PCR) or in situ hybridization (ISH) were carefully retrieved. The included infectious agents were herpes simplex virus (HSV) type 1, 2, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus (EBV), human herpes virus (HHV) 6, 7, 8, parvovirus B19, human papilloma virus, hepatitis B virus, human T-lymphotropic virus 1, Brucella, and Bartonella henselae. RESULTS After an exclusion process of 2491 studies, five, two, four, two, two, and three studies on EBV-PCR, EBV-ISH, HHV6-PCR, HHV8-PCR, parvovirus B19-PCR and HHV7-PCR, respectively, were suitable for quantitative meta-analysis. CONCLUSION The most suspected pathogen, EBV was not associated to KFD than normal controls (odds ratio=0.28, p=0.005), while the HHV8 positivity was more likely to be associated (odds ratio=8.24, p=0.003) although it still needs further verification. None of other viruses was associated to KFD although the results are limited by small sample size. More studies with large sample size and strict sample selection criteria are necessary in future.
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Affiliation(s)
- Yosep Chong
- Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yongdeungpo-gu, Seoul 150-713, Republic of Korea
| | - Chang Suk Kang
- Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yongdeungpo-gu, Seoul 150-713, Republic of Korea.
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Kikuchi-fujimoto disease: a case report and literature review. Case Rep Otolaryngol 2012; 2012:497604. [PMID: 22953115 PMCID: PMC3420536 DOI: 10.1155/2012/497604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 04/09/2012] [Indexed: 12/21/2022] Open
Abstract
Case. 38-year-old lady was referred to the ENT clinic with history of right-sided facial pain, otalgia, and odynophagia. Clinical examination revealed enlarged right-sided lymph nodes in the neck. Further radiological scans showed a mass near the carotid and enlarged level V lymph nodes. Lymphoma was initially suspected. Fine-needle aspiration and excision biopsy were undertaken. Histological analysis later suggested Kikuchi-Fujimoto disease, also known as histiocytic necrotising lymphadenitis. Literature Review. Kikuchi-Fujimoto disease (KFD) was described in 1972 as lymphadenitis with focal proliferation of reticular cells accompanied by numerous histiocytes and extensive nuclear debris. KFD, frequently found in East Asian countries, is rare in the UK. No definite aetiology of KFD is known despite autoimmune and infection factors being suggested. The diagnostic hallmark is histological findings from lymph nodes. Malignancy should be excluded. This condition is mainly self-limiting; hence, management is limited to supportive care. Steroid therapy could be used in severe cases. KFD is relatively unknown in the UK and this case report aims to highlight its occurrence in our population.
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Kim MH, Kim BN, Han TH. Cat-Scratch Disease: A Case Report and Literature Review of Human and Animal Studies Performed in Korea. Infect Chemother 2012. [DOI: 10.3947/ic.2012.44.4.299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Min Hee Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Baek-Nam Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Tae Hee Han
- Department of Laboratory Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Piérard-Franchimont C, Quatresooz P, Piérard GE. Skin diseases associated with Bartonella infection: facts and controversies. Clin Dermatol 2010; 28:483-8. [PMID: 20797506 DOI: 10.1016/j.clindermatol.2010.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The genus Bartonella is composed of a series of species and subspecies. Ten of them are responsible for human infections. The best-identified diseases are cat scratch disease (B henselae and possibly B clarridgeiae), trench fever (B quintana), bacillary angiomatosis (B quintana and B henselae), and the spectrum of verruga peruana, Carrion disease, and Oroya fever (B bacilliformis). Controversies exist about the implication of a few other microorganisms being involved in these diseases. Several other conditions have been associated with the presence of Bartonella spp, but these observations await confirmation.
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Astudillo L. [Kikuchi-Fujimoto disease]. Rev Med Interne 2010; 31:757-65. [PMID: 20605287 DOI: 10.1016/j.revmed.2010.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 11/07/2009] [Accepted: 01/01/2010] [Indexed: 01/30/2023]
Abstract
Kikuchi-Fujimoto disease is a necrotizing lymphadenitis, involving young patients, predominantly females. Lymphadenopathy is usually localized, particularly in the cervical area, mostly unilateral and tender. Fever is present in one third of cases. Associated skin lesions, arthralgia, myalgia, splenomegaly or hepatomegaly are rare. Laboratory evaluation shows a slight increase of erythrocyte sedimentation rate and leukopenia. Kikuchi-Fujimoto has been reported in association with other diseases, including systemic lupus, Still's disease, hemophagocytosis, pregnancy, other autoimmune diseases, and cancer. A viral or bacterial origin has been suspected but not confirmed. Lymph node biopsy allows the diagnosis and shows necrotizing lymphadenitis with acidophil necrosis, CD68+ histiocyte infiltrate, presence of plasmacytoid monocytes, multiple apoptotic cells (CD8+ T cell) with nuclear dust, immunoblastic reaction and the absence of neutrophils or eosinophils. The disease course is usually spontaneously favourable in few weeks or months, requiring corticosteroids only occasionally.
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Affiliation(s)
- L Astudillo
- Service de médecine interne, CHU Purpan, Toulouse cedex, France.
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Yoon HJ, Lee WC, Choi YS, Cho S, Song YG, Choi JY, Kim CO, Kim EJ, Kim JM. Cervical Lymphadenitis in a Patient Coinfected withToxoplasma gondiiandBartonella henselae. Vector Borne Zoonotic Dis 2010; 10:415-9. [DOI: 10.1089/vbz.2008.0175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hee Jung Yoon
- Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea
| | - Woong Chul Lee
- Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea
| | - Young Sill Choi
- Division of Zoonoses, National Institutes of Health, Seoul, Korea
| | - SoungHoon Cho
- Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea
| | - Young Goo Song
- Department of Internal Medicine, Kangnam Severance Hospital, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Oh Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ee-Jin Kim
- Division of Zoonoses, National Institutes of Health, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Atwater AR, Longley BJ, Aughenbaugh WD. Kikuchi's disease: case report and systematic review of cutaneous and histopathologic presentations. J Am Acad Dermatol 2008; 59:130-6. [PMID: 18462833 DOI: 10.1016/j.jaad.2008.03.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 01/30/2008] [Accepted: 03/10/2008] [Indexed: 11/29/2022]
Abstract
Kikuchi's disease, also known as histiocytic necrotizing lymphadenitis, is a systemic illness with classic clinical findings of cervical lymphadenopathy and fever. Diagnosis is confirmed by lymph node histology, which reveals paracortical foci of necrosis and a histiocytic infiltrate. Kikuchi's disease has been associated with a number of infections, but no single source has been identified. Diverse, often nonspecific, cutaneous findings have been described in up to 40% of cases. Description of the histopathologic findings of skin lesions is limited to single case reports and one case series. We describe a 24-year-old woman with fevers, lymphadenopathy, hepatic and hematologic abnormalities, and a skin eruption involving the face, neck, trunk, and extremities with characteristic lymph node and cutaneous histopathologic findings. We completed a systematic review of the clinical presentations and histopathology of Kikuchi's disease.
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Affiliation(s)
- Amber Reck Atwater
- Department of Dermatology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin 53715, USA
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Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch disease: widening spectrum of Bartonella henselae infection. Pediatrics 2008; 121:e1413-25. [PMID: 18443019 DOI: 10.1542/peds.2007-1897] [Citation(s) in RCA: 205] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century. As diagnostic techniques improve, our knowledge of the spectrum of clinical disease resulting from infection with Bartonella is expanding. This review summarizes current knowledge regarding the microbiology, clinical manifestations, diagnostic techniques, and treatment of B. henselae infection.
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Affiliation(s)
- Todd A Florin
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Kalambokis G, Economou G, Nikas S, Bai M, Lampri E, Kosta P, Tsianos EV. Concurrent development of spontaneous pyomyositis due to Staphylococcus epidermidis and Kikuchi-Fujimoto disease. Intern Med 2008; 47:2139-43. [PMID: 19075539 DOI: 10.2169/internalmedicine.47.0946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Staphylococcus epidermidis is a common cause of infections associated with prosthetic devices and immunocompromised patients. Spontaneous pyomyositis due to the above pathogen is very uncommon. Kikuchi-Fujimoto disease (KFD) is a subacute necrotizing lymphadenitis, first described in Japan. A T cell-mediated hyperimmune response to various pathogens in a genetically susceptible individual has been primarily been considered in its pathogenesis. We report a patient who developed spontaneous pyomyositis caused by S. epidermidis concurrently with KFD, and discuss the possibility of S. epidermidis infection being the stimulant of KFD.
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Affiliation(s)
- Georgios Kalambokis
- The 1st Division of Internal Medicine, University Hospital, Ioannina, Greece
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Jöhrens K, Anagnostopoulos I, Dürkop H, Stein H. Different T-bet expression patterns characterize particular reactive lymphoid tissue lesions. Histopathology 2006; 48:343-52. [PMID: 16487356 DOI: 10.1111/j.1365-2559.2005.02305.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To investigate T-bet expression profiles in various lymphoid tissue diseases caused by intracellular pathogens and to compare them in disorders without an infective aetiology. Murine and in vitro experiments have shown that the expression/induction of T-bet, the master regulator of Th1 differentiation, can be achieved by obligate intracellular pathogens and high interferon (IFN)-gamma levels. METHODS Lymph node biopsies were analysed immunohistochemically employing single and double labelling for T-bet and CD20, CD4, CD8 and CD30 detection. RESULTS In disorders associated with high IFN-gamma levels and intracellular pathogens (infectious mononucleosis, HIV-associated lymphadenopathy, cat-scratch disease, and toxoplasmic lymphadenitis), T-bet-expressing CD4 cells were accompanied by significant numbers of T-bet-positive CD8 and B cells. A similar profile was also found in histiocytic necrotizing (Kikuchi) lymphadenitis, a disease of unknown cause. In contrast, T-bet expression in disorders without an infective aetiology was observed in only a small portion of lymphocytes. CONCLUSIONS Increased T-bet expression does not only identify intracellular infections in lymphoid tissue associated with high IFN-gamma levels, but also implies that, under these conditions, it becomes induced in B cells, which apparently support the Th1 response. T-bet expression in Kikuchi lymphadenitis underscores the hypothesis that it is caused by an intracellular microorganism.
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Affiliation(s)
- K Jöhrens
- Institute for Pathology, Charité, Campus Benjamin Franklin, Medical University Berlin, Germany
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Noursadeghi M, Aqel N, Pasvol G. Reply to Angel-Moreno et al. Clin Infect Dis 2006. [DOI: 10.1086/500023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Angel-Moreno A, Hernández-Cabrera M, Pérez-Arellano JL. Kikuchi's Disease or Kikuchi's Syndrome? Clin Infect Dis 2006; 42:578-9; author reply 579-80. [PMID: 16421809 DOI: 10.1086/500017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Kim HA, Chung JY, Kim SW, Lim SJ, Shin HS. Histiocytic necrotizing lymphadenitis in children : association of human herpes virus 8 and Epstein Barr virus. KOREAN JOURNAL OF PEDIATRICS 2006. [DOI: 10.3345/kjp.2006.49.8.875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hyun A Kim
- Department of Pediatrics, College of Medicine, Inje University, Seoul, Korea
| | - Ju-Young Chung
- Department of Pediatrics, College of Medicine, Inje University, Seoul, Korea
| | - Sang Woo Kim
- Department of Pediatrics, College of Medicine, Inje University, Seoul, Korea
| | - Sung Jig Lim
- Department of Pathology, College of Medicine, Inje University, Seoul, Korea
| | - Haeng Seop Shin
- Division of AIDS, National Institute for Health, Seoul, Korea
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