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Sufiawati I, Harmiyati R, Nur’aeny N, Indrati AR, Lesmana R, Wisaksana R, Amalia R. Detection of Human Herpesviruses in Sera and Saliva of Asymptomatic HIV-Infected Individuals Using Multiplex RT-PCR DNA Microarray. Pathogens 2023; 12:993. [PMID: 37623953 PMCID: PMC10457847 DOI: 10.3390/pathogens12080993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/26/2023] Open
Abstract
Human herpesviruses (HHVs) are frequently linked to an increased risk of acquiring human immunodeficiency virus (HIV), and vice versa. This study aimed to detect human herpesvirus (HHV) members in the sera and saliva of asymptomatic HIV-infected individuals. Paired saliva and serum samples were obtained from 30 asymptomatic HIV-infected individuals. HHVs were detected with a multiplex reverse transcription-polymerase chain reaction (RT-PCR) DNA microarray Clart®Entherpex kit. A total of 30 subjects were enrolled: 23 (76.67%) men and 7 (23.33%) women. The present study showed that at least one or more HHV members were detected in the saliva and sera of all (100%) of the subjects. In the saliva, we detected herpes simplex virus 1 (HSV-1) 6.67%, herpes simplex virus 2 (HSV-2) 6.67%, Epstein-Barr virus (EBV) 86.67%, cytomegalovirus (CMV) 63.33%, HHV-6 (40%), and HHV-7 (83.33%). In the sera, HSV-2 (20%), EBV (30%), CMV (40%), HHV-6 (0%), and HHV-7 (76.67%) were found, but not HSV-1. VZV and HHV-8 were not detected in either the saliva or sera. EBV and HHV6 were significantly more prevalent in the saliva than they were in the sera of asymptomatic HIV-infected individuals (p < 0.05). However, no significant differences were found in the prevalence of HSV-1, EBV, CMV, HHV-6, and HHV-7 in the saliva and sera of asymptomatic HIV-infected individuals (p > 0.05). In conclusion, the multiplex RT-PCR DNA microarray can serve as a valuable diagnostic tool that can be used as a screening tool or a first-line test for HHVs infections.
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Affiliation(s)
- Irna Sufiawati
- Department of Oral Medicine, Faculty of Dentistry, University of Padjadjaran, Bandung 40132, Indonesia;
| | - Rahmi Harmiyati
- Oral Medicine Residency Program, Faculty of Dentistry, University of Padjadjaran, Bandung 40132, Indonesia;
| | - Nanan Nur’aeny
- Department of Oral Medicine, Faculty of Dentistry, University of Padjadjaran, Bandung 40132, Indonesia;
| | - Agnes Rengga Indrati
- Department of Clinical Pathology, Faculty of Medicine, University of Padjadjaran, Bandung 45363, Indonesia;
| | - Ronny Lesmana
- Department of Biomedical Sciences, Faculty of Medicine, University of Padjadjaran, Bandung 45363, Indonesia;
| | - Rudi Wisaksana
- Department of Internal Medicine, Faculty of Medicine, University of Padjadjaran, Dr. Hasan Sadikin Central General Hospital, Bandung 45363, Indonesia;
| | - Riezki Amalia
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Padjadjaran, Bandung 45363, Indonesia;
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Hadi AM, Mohammed Al-Alwany SH, Al-Khafaji ZA, Sharaf M, Mofed D, Khan TU. Molecular diagnosis of Herpes virus type 1 by glycoprotein receptor primers. GENE REPORTS 2022. [DOI: 10.1016/j.genrep.2021.101479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Barros KMA, Ribeiro Paulino M, Batista MIHDM, Gueiros LAM, Souza PRED, Leão JC, de Albuquerque Tavares Carvalho A. Absence of influence of polymorphisms of the MBL2 gene in oral infections by HSV-1 in individuals with HIV. Braz J Microbiol 2019; 50:663-668. [PMID: 31001794 DOI: 10.1007/s42770-019-00074-6] [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: 10/08/2018] [Accepted: 02/25/2019] [Indexed: 11/30/2022] Open
Abstract
Polymorphisms in the structural gene MBL-2 (mannose-binding lectin-2) may result in low MBL serum concentration, associated with greater susceptibility to infection. The study evaluated the effects of MBL-2 polymorphisms with the oral manifestations of the HSV in human immunodeficiency virus (HIV)-infected patients. An observational case-control study was carried out, with the sample comprising 64 HIV+ and 65 healthy individuals. The signs and symptoms of HSV oral infection were evaluated, and oral mucosa buccal smears were collected. Polymorphisms of the MBL-2 gene and HSV-1 DNA were amplified through real-time PCR. The data revealed that of 64 HIV+, 29.6% presented signs and symptoms of HSV oral infection. Of these, the HSV-1 DNA was detected through real-time PCR in 21% of cases, and in 13.3% of asymptomatic individuals. There was no statistically significant difference between the symptomatic (p = 1) and the asymptomatic (p = 0.52) individuals, HIV+ and HIV-. Different genotypes (AA, A0, or 00) did not contribute to the oral manifestation of HSV in the HIV+ patients (p = 0.81) or HIV- (p = 0.45). There was no statistically significant difference in either group (p = 0.52). No significant association was identified between the MBL-2 gene polymorphisms in the oral manifestation of HSV infection. However, further studies are recommended with larger population groups before discarding this interrelationship.
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Affiliation(s)
| | - Marcília Ribeiro Paulino
- University Federal of Pernambuco (UFPE), Av. Prof. Moraes Rego, 1235, Recife, PE, 50670-901, Brazil.
| | | | | | | | - Jair Carneiro Leão
- University Federal of Pernambuco (UFPE), Av. Prof. Moraes Rego, 1235, Recife, PE, 50670-901, Brazil
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Palmieri M, Ornaghi M, Martins VADO, Correa L, Brandao TB, Ribeiro ACDP, Sumita LM, Tozetto-Mendoza TR, Pannuti CS, Braz-Silva PH. Oral shedding of human herpesviruses in patients undergoing radiotherapy/chemotherapy for head and neck squamous cell carcinoma is not affected by xerostomia. J Oral Microbiol 2018; 10:1476643. [PMID: 29868164 PMCID: PMC5974707 DOI: 10.1080/20002297.2018.1476643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 05/11/2018] [Indexed: 01/22/2023] Open
Abstract
Background: Xerostomia is a very relevant and frequent complication of radiotherapy, causing the irradiated oral mucosa to be affected by bacterial, fungal and viral infections. Objective: The objective of this study was to evaluate a possible relationship between oral shedding of human herpesviruses and xerostomia in patients with squamous cell carcinoma of head and neck submitted to radio/chemotherapy. Methods: In this study, oral rinse samples were collected weekly from 20 patients during radiotherapy. The samples were submitted to PCR and enzymatic digestion for detection of human herpesviruses. Xerostomia was evaluated according to the Seminars in Radiation Oncology criteria. Results: There was a higher frequency of grade 1 xerostomia (51.4%), observed first in the 1st week of radiotherapy. In the 4th week of radiotherapy, all patients presented some degree of xerostomia. Analysis of herpesviruses showed oral shedding of EBV, HHV-6 and HHV-7 in all weeks. Considering all the periods, the highest frequency was in patients with EBV excretion (55.0%), which was significantly higher than that of other viruses. Conclusion: We observed that oral shedding of herpesviruses was not affected by xerostomia as there was a progression in their excretion, even with the evolution of xerostomia. This suggested that there is a local replication in the oral cavity that is not completely dependent of salivary excretion.
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Affiliation(s)
- Michelle Palmieri
- Division of Pathology, Department of Stomatology, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil
| | - Mariana Ornaghi
- Division of Pathology, Department of Stomatology, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Luciana Correa
- Division of Pathology, Department of Stomatology, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil
| | - Thais Bianca Brandao
- Division of Dentistry, Instituto do Cancer do Estado de Sao Paulo Octavio Frias de Oliveira, Sao Paulo, Brazil
| | | | - Laura Masami Sumita
- Laboratory of Virology, Institute of Tropical Medicine of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Claudio Sergio Pannuti
- Laboratory of Virology, Institute of Tropical Medicine of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Paulo Henrique Braz-Silva
- Division of Pathology, Department of Stomatology, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil.,Laboratory of Virology, Institute of Tropical Medicine of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
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Abstract
OBJECTIVE We evaluated the subclinical shedding of six different herpesviruses in antiretroviral drug-treated HIV-positive [HIV(+)] MSM, and determined how this is associated with markers of inflammation and immune activation. METHODS We obtained blood, semen, throat washing, urine, and stool from 15 antiretroviral-treated HIV-1-infected MSM with CD4 T-cell reconstitution, and 12 age-matched HIV-negative [HIV (-)] MSM from the Multicenter AIDS Cohort Study at four timepoints over 24 weeks to measure DNA levels of cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus 1 and 2, human herpesvirus 6 (HHV6), and HHV8. T-cell activation and plasma levels of soluble markers of inflammation and activation were also measured at the corresponding timepoints. RESULTS HIV(+) participants had a trend for higher total herpesvirus shedding rate. HIV(+) participants also had a significantly higher rate of shedding EBV and CMV compared with the HIV(-) group. Herpesvirus shedding was mostly seen in throat washings. In the HIV(+) group, herpesvirus shedding rate inversely correlated with plasma levels of interferon γ-induced protein 10 and soluble CD163. CMV DNA levels negatively correlated with levels of T-cell activation. There was a trend for a positive correlation between EBV shedding rate and plasma soluble CD14. HHV6 shedding rate negatively correlated with plasma levels of interleukin-6, soluble CD163, and interferon gamma-induced protein 10. Correlations were not observed among HIV(-) individuals. CONCLUSION Among treated HIV-infected MSM, there are higher subclinical shedding rates of some herpesviruses that occur in different body compartments and negatively correlate with levels of inflammation and immune activation.
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Malamos D, Scully C. Sore or Swollen Lips Part 3: Diagnosis and Treatment. DENTAL UPDATE 2017; 44:70-74. [PMID: 29172315 DOI: 10.12968/denu.2017.44.1.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips. Clinical relevance: Sore and/or swollen lips are not uncommon, often have a local cause but may reflect a systemic disease. The previous 2 papers in the series discussed their causes. This paper reviews their diagnosis and treatment.
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Palmieri M, Martins VADO, Sumita LM, Tozetto-Mendoza TR, Romano BB, Machado CM, Pannuti CS, Brandão TB, Ribeiro ACP, Corrêa L, Braz-Silva PH. Oral shedding of human herpesviruses in patients undergoing radiotherapy/chemotherapy treatment for head and neck squamous cell carcinoma. Clin Oral Investig 2016; 21:2291-2301. [DOI: 10.1007/s00784-016-2022-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
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Yengopal V, Kolisa Y, Thekiso MD, Molete MP. The child and adolescent with HIV in resource poor countries. Oral Dis 2016; 22 Suppl 1:25-34. [PMID: 26879655 DOI: 10.1111/odi.12411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Although sub-Saharan Africa caries the burden of paediatric and adult HIV/AIDS infections, the epidemic is spreading most rapidly in the Middle East and North Africa Region where between 2005 and 2013, AIDS-related deaths increased by 66% in comparison with a worldwide fall of 35%. For the first time, in 2011, more than half of people in need of antiretroviral drugs were receiving them, with coverage reaching 54%; yet only 28% of children have access to HIV treatment. This review sought to provide an update of paediatric and adolescent oral HIV/AIDS issues in resource poor countries. OBJECTIVES To review the literature on paediatric & adolescent HIV with a focus on oral lesions as predictors of HIV infection; as markers of the efficacy of HAART and quality of life; caries risk; management of oral lesions; and epidemiological tests for clinical significance of oral lesions. METHODS A search strategy was developed for PubMed to identify papers on paediatric oral HIV. Publications in English were selected on the basis that their titles and abstracts were relevant to the review objectives. The reference lists of included papers were screened for additional articles. The time-search for publications was limited from 2009 to 15 October 2014. RESULTS Papers on the prevalence of oral lesions lacked standardization in diagnostic criteria and the introduction of HAART had significantly reduced prevalence; oral lesions remain useful predictors for HIV infection and as markers for the efficacy of HAART. Evidence suggest that caries risk is increased with HIV infection; management of oral lesions is inconsistent with available resources and surprisingly little recent information has been published in the past 5 years. Revised case definitions are proposed for large-scale epidemiologic studies with the development of an oral lesion index showing promise. Oral health quality of life indicators for children and adolescents are becoming important as more of these indicators are being developed and their negative oral impacts in individuals with oral lesions are now well established. CONCLUSIONS Paediatric and adolescent oral HIV research needs to be prioritized as current studies are few and are characterized by poor quality study designs, small study samples and a lack of multicentre collaborations. There is a lack of high quality evidence for a number of interventions available for management of oral lesions.
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Affiliation(s)
- V Yengopal
- Department of Community Dentistry, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Y Kolisa
- Department of Community Dentistry, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M D Thekiso
- Department of Community Dentistry, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M P Molete
- Department of Community Dentistry, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Otero RA, Nascimento FNN, Souza IPR, Silva RC, Lima RS, Robaina TF, Câmara FP, Santos N, Castro GF. LACK OF ASSOCIATION BETWEEN HERPESVIRUS DETECTION IN SALIVA AND GINGIVITIS IN HIV‑INFECTED CHILDREN. Rev Inst Med Trop Sao Paulo 2016. [PMID: 26200962 PMCID: PMC4544246 DOI: 10.1590/s0036-46652015000300007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The aims of this study were to compare the detection of human herpesviruses (HHVs) in
the saliva of HIV-infected and healthy control children, and to evaluate associations
between viral infection and gingivitis and immunodeficiency. Saliva samples were
collected from 48 HIV-infected and 48 healthy control children. Clinical and
laboratory data were collected during dental visits and from medical records. A
trained dentist determined gingival indices and extension of gingivitis. Saliva
samples were tested for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2),
varicella zoster virus (VZV), Epstein-Barr virus (EBV), and cytomegalovirus (CMV) by
nested polymerase chain reaction assays. Thirty-five HIV-infected and 16 control
children had gingivitis. Seventeen (35.4%) HIV-infected children and 13 (27%) control
children were positive for HHVs. CMV was the most commonly detected HHV in both
groups (HIV-infected, 25%; control, 12.5%), followed by HSV-1 (6.2% in both groups)
and HSV-2 (HIV-infected, 4.2%; control, 8.3%). The presence of HHVs in saliva was not
associated with the presence of gingivitis in HIV-1-infected children
(p = 0.104) or healthy control children (p =
0.251), or with immunosuppression in HIV-infected individuals (p =
0.447). Gingivitis was correlated with HIV infection (p = 0.0001).
These results suggest that asymptomatic salivary detection of HHVs is common in
HIV-infected and healthy children, and that it is not associated with gingivitis.
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Affiliation(s)
- Renata A Otero
- Department of Pediatric Dentistry, School of Dentistry, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Flávia N N Nascimento
- Department of Pediatric Dentistry, School of Dentistry, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Ivete P R Souza
- Department of Pediatric Dentistry, School of Dentistry, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Raquel C Silva
- Department of Virology, Microbiology Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Rodrigo S Lima
- Department of Virology, Microbiology Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Tatiana F Robaina
- Department of Virology, Microbiology Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Fernando P Câmara
- Department of Virology, Microbiology Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Norma Santos
- Department of Virology, Microbiology Institute, Universidade Federal do Rio de Janeiro, RJ, Brazil
| | - Gloria F Castro
- Department of Pediatric Dentistry, School of Dentistry, Universidade Federal do Rio de Janeiro, RJ, Brazil
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Bezerra TM, Ferreira DC, Carmo FL, Pinheiro R, Leite DCA, Cavalcante FS, Belinho RA, Peixoto RS, Rosado AS, dos Santos KRN, Castro GFBA. Herpesvirus in the oral cavity of children with leukaemia and its impact on the oral bacterial community profile. J Clin Pathol 2015; 68:222-8. [DOI: 10.1136/jclinpath-2014-202668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Fontes TV, Ferreira SMS, Silva-Júnior A, Dos Santos Marotta P, Noce CW, Ferreira DDC, Gonçalves LS. Periradicular lesions in HIV-infected patients attending the faculty of dentistry: clinical findings, socio-demographics status, habits and laboratory data - seeking an association. Clinics (Sao Paulo) 2014; 69:627-33. [PMID: 25318095 PMCID: PMC4192428 DOI: 10.6061/clinics/2014(09)09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/27/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The purpose of this study was to estimate the prevalence of periradicular lesions in HIV-infected Brazilian patients and to assess the correlation of several factors with the periradicular status. METHOD One hundred full-mouth periapical radiographs were evaluated. A total of 2,214 teeth were evaluated for the presence of periradicular lesions, caries lesions, coronal restorations, pulp cavity exposure and endodontic treatment. RESULTS The prevalence of periradicular lesions was 46%. There were no significant differences between individuals with or without periradicular lesions with respect to their socio-demographic status, habits, laboratory data and route of HIV infection. However, the presence of a periradicular lesion was statistically correlated with the number of teeth with endodontic treatment (p = 0.018), inadequate endodontic treatment (p = 0.025), images suggesting pulp cavity exposure (p = 0.002) and caries lesions (p = 0.001). CONCLUSIONS The prevalence of periradicular lesions in HIV-infected individuals was 46% and was not related to HIV infection.
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Affiliation(s)
| | | | - Arley Silva-Júnior
- Oral Pathology, Fluminense Federal University, Rio de Janeiro, RJ, Brazil
| | | | - Cesar Werneck Noce
- Oral Pathology, Fluminense Federal University, Rio de Janeiro, RJ, Brazil
| | - Dennis de Carvalho Ferreira
- Proc. n° BEX 9203, Bolsista da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), CAPES Foundation, Brasília, DF, Brazil
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Zuckerman R, Manji K, Matee M, Naburi H, Bisimba J, Martinez R, Wieland-Alter W, Kim F, von Reyn CF, Palumbo P. HSV oropharyngeal shedding among HIV-infected children in Tanzania. Int J STD AIDS 2014; 26:456-61. [PMID: 25028453 DOI: 10.1177/0956462414543122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/15/2014] [Indexed: 11/15/2022]
Abstract
Herpes simplex virus (HSV) oral shedding has not been studied among HIV-positive children in Africa. We sought to evaluate longitudinal oral HSV reactivation in HIV-positive and -negative children. Twenty HIV-positive antiretroviral-naive and 10 HIV-negative children aged 3-12 years in Tanzania were followed prospectively for 14 days. Oral swabs were collected daily and submitted for HSV DNA PCR analysis. Clinical data were collected via chart review and daily diaries. HSV DNA was detected in 10 (50%) of HIV-positive and 4 (40%) of HIV-negative children. Children who shed HSV had virus detected in a median of 21.4% of samples; shedding was intermittent. Median CD4 count among HIV-infected children was 667 cells/µL in those with positive HSV DNA and 886 cells/µL in those who were negative (p = 0.6). Of the HIV-positive children reporting prior sores, five (83%) had positive HSV swabs, whereas the one HIV-negative child with prior sores did not have a PCR-positive swab. HSV is detected frequently in children with and without HIV. HIV-infected children reporting oral sores have a high rate of HSV detection. Given the proven strong interactions between HIV and HSV, further study of co-infection with these viruses is warranted in children.
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Affiliation(s)
- Richard Zuckerman
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA Dartmouth College, Hanover, NH, USA
| | - Karim Manji
- DarDar Pediatric Program, Dar es Salaam, United Republic of Tanzania Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Mecky Matee
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Helga Naburi
- DarDar Pediatric Program, Dar es Salaam, United Republic of Tanzania Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Jema Bisimba
- DarDar Pediatric Program, Dar es Salaam, United Republic of Tanzania
| | - Raquel Martinez
- Dartmouth College, Hanover, NH, USA Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Paul Palumbo
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA Dartmouth College, Hanover, NH, USA DarDar Pediatric Program, Dar es Salaam, United Republic of Tanzania
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