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Liang S, Liang H, Huang X, Liang X, Chen N, Xiao R, Luo Z, Chen Q, Zhong X, Deng J, Huang J, Li M, Yang M, Zeng W, Tang H, Jiang J, Qin S, Wei Z, Wu S, Ning Y, Wang K, Cao F, Zhang J, Wei Q, Xu C, Luo H, Song J, Li P, Feng X, Yang C, Lei J, Wang H, Cao B, He Z. Clinical immunological characteristics of anti-interferon-γ autoantibodies syndrome: a 3 year prospective cohort study. Emerg Microbes Infect 2024; 13:2396887. [PMID: 39178284 PMCID: PMC11378669 DOI: 10.1080/22221751.2024.2396887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/24/2024] [Accepted: 08/22/2024] [Indexed: 08/25/2024]
Abstract
Anti-interferon-γ autoantibodies (AIGAs) syndrome is susceptible to disseminated opportunistic infections due to increased AIGAs, but its clinical immunological characteristics remain unrecognized. We conducted a prospective cohort study between January 2021 and December 2023, recruiting patients with opportunistic infections who were categorized into AIGAs-positive and AIGAs-negative groups. Clinical immunological data and outcomes were documented. A subset of AIGAs-positive patients received glucocorticoid treatment, and its effectiveness was evaluated. A total of 238 patients were enrolled, with 135 AIGAs-positive and 103 AIGAs-negative patients. AIGAs-positive patients showed higher rates of multiple pathogen dissemination, shorter progression-free survival (PFS), and increased exacerbation frequency. They also showed elevated erythrocyte sedimentation rate (ESR), globulin (GLB), immunoglobulin (Ig)G, IgE, and IgG4 levels. Among the 70 AIGAs-positive patients monitored for at least six months, three subtypes were identified: high AIGAs titer with immune damage, high AIGAs titer without immune damage, and low AIGAs titer without immune damage. Of the 55 patients followed for 1 year, decreasing AIGAs titer and immune indices (GLB, IgG, IgE, IgG4) were observed. Among the 31 patients with high AIGAs titer and immune damage treated with low-dose glucocorticoids at the stable phase, reductions were observed in immune indices and AIGAs titer in 67.74% of cases. In summary, AIGAs-positive patients exhibit infectious and immunological characteristics. Elevated AIGAs, IgG, IgG4, and IgE indicate abnormal immune damages. AIGAs titer generally decrease over time. Stable-phase AIGAs-positive patients can be categorized into three subtypes, with those having high AIGAs titer and increased immune indices potentially benefitting from glucocorticoid treatment.
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Affiliation(s)
- Siqiao Liang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Hanlin Liang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Xuemei Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Xiaona Liang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Ni Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Rong Xiao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Zengtao Luo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Quanfang Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Xinxin Zhong
- Department of Respiratory and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, People’s Republic of China
| | - Jingmin Deng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jie Huang
- Department of Tuberculosis, Nanning Fourth People's Hospital, Nanning, People’s Republic of China
| | - Meihua Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Meiling Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Wen Zeng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Haijuan Tang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jing Jiang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Shouming Qin
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Zhen Wei
- Department of Respiratory and Critical Care Medicine, The People Hospital of Hechi, Hechi, People’s Republic of China
| | - Siyao Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yan Ning
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Fu Cao
- Department of Respiratory and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, People’s Republic of China
| | - Jiujin Zhang
- Department of Respiratory and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, People’s Republic of China
| | - Qing Wei
- Department of Respiratory and Critical Care Medicine, The People Hospital of Hechi, Hechi, People’s Republic of China
| | - Chengqiong Xu
- Department of Respiratory and Critical Care Medicine, The Second People’s Hospital of Qinzhou, Qinzhou, People’s Republic of China
| | - Honglin Luo
- Institute of Oncology, Guangxi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Jian Song
- Institute of Cardiovascular Sciences, Guangxi Academy of Medical Sciences, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Pei Li
- Infectious Diseases Division, KingMed Diagnostics, Guangzhou, People’s Republic of China
| | - Xiaokai Feng
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-yang Hospital, Beijing, People’s Republic of China
| | - Chenlu Yang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, People’s Republic of China
| | - Jieping Lei
- Department of Clinical Research and Data Management, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Hongwei Wang
- Basic Medical College, Medical School of Nanjing University, Nanjing, People’s Republic of China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China–Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Zhiyi He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Vinh DC. From Mendel to mycoses: Immuno-genomic warfare at the human-fungus interface. Immunol Rev 2024; 322:28-52. [PMID: 38069482 DOI: 10.1111/imr.13295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 03/20/2024]
Abstract
Fungi are opportunists: They particularly require a defect of immunity to cause severe or disseminated disease. While often secondary to an apparent iatrogenic cause, fungal diseases do occur in the absence of one, albeit infrequently. These rare cases may be due to an underlying genetic immunodeficiency that can present variably in age of onset, severity, or other infections, and in the absence of a family history of disease. They may also be due to anti-cytokine autoantibodies. This review provides a background on how human genetics or autoantibodies underlie cases of susceptibility to severe or disseminated fungal disease. Subsequently, the lessons learned from these inborn errors of immunity marked by fungal disease (IEI-FD) provide a framework to begin to mechanistically decipher fungal syndromes, potentially paving the way for precision therapy of the mycoses.
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Affiliation(s)
- Donald C Vinh
- Infectious Diseases - Hematology/Oncology/Transplant Clinical Program, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Centre of Excellence for Genetic Research in Infection and Immunity, Research Institute - McGill University Health Centre, Montreal, Quebec, Canada
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3
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Zheng JH, Wu D, Guo XY. Intracranial infection accompanied sweet’s syndrome in a patient with anti-interferon-γ autoantibodies: A case report. World J Clin Cases 2023; 11:7926-7934. [DOI: 10.12998/wjcc.v11.i32.7926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Several reports of adult-onset immunodeficiency syndrome have been associated with anti-interferon-gamma (IFN-γ) autoantibodies (AIGAs). However, it is rare to find AIGAs with intracranial infections.
CASE SUMMARY In this case study, we report a case of an AIGAs with intracranial infection and hand rashes considered Sweet’s syndrome. The patient presented to our hospital with a persistent cough, a fever that had been going on for 6 mo, and a rash that had been going on for a week. The patient started losing consciousness gradually on the fourth day after admission, with neck stiffness and weakened limb muscles. The upper lobe of the left lung had a high-density mass with no atypia and a few inflammatory cells in the interstitium. Brain magnetic resonance imaging and cerebrospinal fluid suggest intracranial infection. The pathology of the skin damage on the right upper extremity revealed an infectious lesion that was susceptible to Sweet’s disease. It has an anti-IFN-γ autoantibody titer of 1:2500. She was given empirical anti-non-tuberculous mycobacterial and antifungal treatments. The patient had no fever, obvious cough, headache, or rash on the hand. She got out of bed and took care of herself following hospitalization and discharge with medicine.
CONCLUSION Adults with severe and recurrent infections of several organs should be considered for AIGAs if no other known risk factors exist. AIGAs are susceptible to subsequent intracranial infections and Sweet’s syndrome.
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Affiliation(s)
- Jun-Hui Zheng
- General Internal Medicine, Affiliated Cancer Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Dan Wu
- Department of Intensive Care Unit, Affiliated Cancer Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Yun Guo
- General Internal Medicine, Affiliated Cancer Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Matos AC, Jota Baptista C, Oliveira PA, Soares AS, Figueira L, Matos M, Coelho AC. First morphological and molecular isolation of Talaromyces marneffei in beech marten (Martes foina) in Portugal. Res Vet Sci 2023; 162:104945. [PMID: 37421825 DOI: 10.1016/j.rvsc.2023.104945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/02/2023] [Accepted: 07/01/2023] [Indexed: 07/10/2023]
Abstract
Talaromyces marneffei is a zoonotic fungus that mostly infects immunocompromised individuals. For the first time, this fungus was isolated in an adult beech marten (Martes foina) hit by a car, found dead in Penamacor, Portugal. During the necropsy, different samples (skin, fur, lymph nodes, lung, spleen, kidneys, and brain) were collected and processed for microbiology (including mycology) and molecular biology. T. marneffei was identified through its mycological characteristics and confirmed by PCR in hair samples. No other lesions or alterations were reported, except a concomitant presence of M. avium subsp. paratuberculosis in lung, kidney and brain samples. To the authors' knowledge, this is the first description of this fungus beech marten, as well as the first case of co-infection with M. avium subsp. paratuberculosis in wildlife fauna. These results suggest a sylvatic life-cycle of T. marneffei, involving beech martens, in Portugal.
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Affiliation(s)
- Ana Cristina Matos
- CERNAS, Research Center for Natural Resources, Environment and Society, Polytechnic Institute of Castelo Branco, 6000-084 Castelo Branco, Portugal; QRural- Quality of Life in the Rural World- Research Unit, Polytechnic Institute of Castelo Branco, 6000-084 Castelo Branco, Portugal
| | - Catarina Jota Baptista
- Department of Veterinary Sciences, University of Trás-os-Montes e Alto Douro (UTAD), Quinta de Prados, 5000-801 Vila Real, Portugal; Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB), Inov4Agro - Institute for Innovation, Capacity Building and Sustainability of Agri-food Production, UTAD, Vila Real, Portugal; IBIOMED - Instituto de Biomedicina de la Universidad de León, León, Spain; Faculty of Veterinary Medicine, Lusófona University of Humanities and Technologies (FMV-ULHT), Lisbon; Portugal.
| | - Paula A Oliveira
- Department of Veterinary Sciences, University of Trás-os-Montes e Alto Douro (UTAD), Quinta de Prados, 5000-801 Vila Real, Portugal; Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB), Inov4Agro - Institute for Innovation, Capacity Building and Sustainability of Agri-food Production, UTAD, Vila Real, Portugal
| | - Ana Sofia Soares
- CECAV - Animal and Veterinary Research Centre, Vila Real, Portugal; Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS), Portugal
| | - Luís Figueira
- QRural- Quality of Life in the Rural World- Research Unit, Polytechnic Institute of Castelo Branco, 6000-084 Castelo Branco, Portugal
| | - Manuela Matos
- Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB), Inov4Agro - Institute for Innovation, Capacity Building and Sustainability of Agri-food Production, UTAD, Vila Real, Portugal; Department of Genetics and Biotechnology, UTAD, 5000-801, Vila Real, Portugal
| | - Ana Cláudia Coelho
- Department of Veterinary Sciences, University of Trás-os-Montes e Alto Douro (UTAD), Quinta de Prados, 5000-801 Vila Real, Portugal; CECAV - Animal and Veterinary Research Centre, Vila Real, Portugal; Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS), Portugal
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5
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Wang H, Lei R, Ji Y, Xu W, Zhang K, Guo X. Multiple refractory intracellular pathogen infections in a human immunodeficiency virus-negative patient with anti-interferon-γ autoantibodies: a case report. BMC Infect Dis 2023; 23:493. [PMID: 37495965 PMCID: PMC10373241 DOI: 10.1186/s12879-023-08404-8] [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: 11/30/2022] [Accepted: 06/17/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND The clinical presentation of adult-onset immunodeficiency with anti-interferon (IFN)-γ autoantibodies with intracellular pathogens can be highly variable, which can lead to misdiagnosis during the early stage of disease. CASE PRESENTATION We report a complex case of a 54-year-old Chinese male who was human immunodeficiency virus-negative. He had a presence of anti-IFN-γ autoantibodies and suffered from various intracellular pathogenic infections. The patient was admitted to our hospital for the first time in July 2016 with severe pneumonia, and he experienced multiple pneumonia infections between 2017 and 2019. In March 2019, the patient was hospitalized due to pulmonary lesions and multiple-bone destruction. During hospitalization, the patient was confirmed to have disseminated Talaromyces marneffei infection and was successfully treated with antifungal therapy for 1 year. In June 2021, Mycobacterium kansasii infection was detected by positive culture and progressive bone destruction. A high concentration of anti-IFN-γ antibodies was observed in the patient's serum. In addition, Listeria monocytogenes was isolated by blood culture, and the presence of L. monocytogenes in cerebrospinal fluid was confirmed by next-generation sequencing. Following anti-non-tuberculous mycobacteria (NTM) therapy and anti-bacterial therapy, the patient's symptoms, pulmonary lesions, and bone destruction gradually improved. CONCLUSIONS Although the clinical presentation of adult-onset immunodeficiency with anti-IFN-γ autoantibodies can be highly variable, the diagnosis should be considered if patients suffer from unexplained repeated bacterial or opportunistic infections. Conventional and advanced molecular testing should be used, as needed, for microbiological diagnoses among this special immunodeficient population.
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Affiliation(s)
- Hongxia Wang
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China.
- , Shenzhen, China.
| | - Rong Lei
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China.
| | - Yang Ji
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China
| | - Wei Xu
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China
| | - Keke Zhang
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China
| | - Xiang Guo
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1St Road, Futian District, Shenzhen, Guangdong, China
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Yu Q, Wei M, Xiao R, Liang X, Liang S, Ma N, Wu S, Ning Y, Deng J, Yang M, Chen Q, Zeng W, Li M, Feng X, He Z. Clinical Characteristics, Course, and Long-Term Outcomes in Patients with Talaromyces marneffei Infection: A 10-Year Retrospective Cohort Study. Infect Dis Ther 2023; 12:1283-1297. [PMID: 37055706 DOI: 10.1007/s40121-023-00801-5] [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: 01/03/2023] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Talaromyces marneffei (T. marneffei), a dimorphic fungus, causes local or disseminated infection in humans. We aimed to analyze the clinical characteristics, prognostic factors, and survival outcomes of patients with T. marneffei infection and compare the differences between human immunodeficiency virus (HIV)-positive and HIV-negative subgroups. METHODS We retrospectively analyzed 241 patients with T. marneffei infection at the First Affiliated Hospital of Guangxi Medical University between January 2012 and January 2022. The overall population was stratified into HIV-positive (n = 98) and HIV-negative (n = 143) groups according to HIV status. Kaplan-Meier analysis and multivariate Cox regression models were used to determine the prognostic factors for overall survival (OS) and progression-free survival (PFS). RESULTS With a median follow-up time of 58.9 months, 120 patients (49.8%) experienced disease progression and 85 patients (70.8%) died. The 5-year rates of OS and PFS were 61.4% (95% CI 55.0-68.6%) and 47.8% (95% CI 41.5-55.1%), respectively. As an independent factor, patients who were HIV positive had better PFS (HR 0.50, 95% CI 0.31-0.82; p < 0.01) than patients who were HIV negative. Compared with patients who were HIV positive, patients who were HIV negative were older and had more probabilities of underlying diseases, chest involvement, bone destruction, and higher count of neutrophils (all p < 0.05). Hemoglobin (PFS: HR 0.62; 95% CI 0.39-1.00; p < 0.05; OS: HR 0.45; 95% CI 0.22-0.89; p = 0.02) and lymphocyte count (PFS: HR 0.06; 95% CI 0.01-0.26; p < 0.01; OS: HR 0.08; 95% CI 0.01-0.40; p < 0.01) were independent prognostic factors for PFS and OS in patients who were HIV negative. CONCLUSIONS Patients with T. marneffei infection have a poor prognosis. Patients who are HIV positive and HIV negative have relatively independent clinical characteristics. Multiple organ involvement and disease progression are more common in patients who are HIV negative.
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Affiliation(s)
- QingLiang Yu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Meifang Wei
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Rong Xiao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Xiaona Liang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Siqiao Liang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Nan Ma
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Siyao Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Yan Ning
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Jingmin Deng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Meiling Yang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Quanfang Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Wen Zeng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Meihua Li
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China
| | - Xiaokai Feng
- Department of Pulmonary and Critical Care Medicine, No. 8, Gongti South Road, Chaoyang District, Beijing, People's Republic of China.
| | - Zhiyi He
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, People's Republic of China.
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7
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Of Mycelium and Men: Inherent Human Susceptibility to Fungal Diseases. Pathogens 2023; 12:pathogens12030456. [PMID: 36986378 PMCID: PMC10058615 DOI: 10.3390/pathogens12030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Abstract
In medical mycology, the main context of disease is iatrogenic-based disease. However, historically, and occasionally, even today, fungal diseases affect humans with no obvious risk factors, sometimes in a spectacular fashion. The field of “inborn errors of immunity” (IEI) has deduced at least some of these previously enigmatic cases; accordingly, the discovery of single-gene disorders with penetrant clinical effects and their immunologic dissection have provided a framework with which to understand some of the key pathways mediating human susceptibility to mycoses. By extension, they have also enabled the identification of naturally occurring auto-antibodies to cytokines that phenocopy such susceptibility. This review provides a comprehensive update of IEI and autoantibodies that inherently predispose humans to various fungal diseases.
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8
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Qiu Y, Fang G, Ye F, Zeng W, Tang M, Wei X, Yang J, Li Z, Zhang J. Pathogen spectrum and immunotherapy in patients with anti-IFN-γ autoantibodies: A multicenter retrospective study and systematic review. Front Immunol 2022; 13:1051673. [PMID: 36569827 PMCID: PMC9772057 DOI: 10.3389/fimmu.2022.1051673] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Background Anti-interferon-γ autoantibody (AIGA) positivity is an emerging immunodeficiency syndrome closely associated with intracellular infection in individuals without human immunodeficiency virus (HIV). However, the information on epidemiology, pathogen spectrum, and immunotherapy among these patients lack a systematic description of large data. Methods This systematic literature review and multicenter retrospective study aimed to describe the pathogen spectrum and review treatment strategies among patients with AIGA positivity. Results We included 810 HIV-negative patients with AIGA positivity infected with one or more intracellular pathogens. Excluding four teenagers, all the patients were adults. The most common pathogen was nontuberculous mycobacteria (NTM) (676/810, 83.5%). A total of 765 NTM isolates were identified in 676 patients with NTM, including 342 (44.7%) rapid-grower mycobacteria, 273 (35.7%) slow-grower mycobacteria, and 150 (19.6%) unidentified NTM subtype. Even with long-term and intensive antimicrobial treatments, 42.6% of patients with AIGA positivity had recurrence and/or persistent infection. Sixty-seven patients underwent immunoregulatory or immunosuppressive therapy, and most (60) achieved remission. The most common treatment strategy was rituximab (27/67, 40.3%) and cyclophosphamide (22/67, 32.8%), followed by cyclophosphamide combined with glucocorticoids (8/67, 11.9%). Conclusions Intracellular pathogen was the most common infection in patients with AIGA positivity. The predominant infection phenotypes were NTM, varicella-zoster virus, Talaromyces marneffei, and Salmonella spp., with or without other opportunistic infections. AIGA immunotherapy, including rituximab or cyclophosphamide, has yielded good preliminary results in some cases.
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Affiliation(s)
- Ye Qiu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China,Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China,Department of General medicine, The Cancer Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Gaoneng Fang
- Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China,Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wen Zeng
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Mengxin Tang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xuan Wei
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jinglu Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhengtu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,*Correspondence: Jianquan Zhang, ; Zhengtu Li,
| | - Jianquan Zhang
- Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China,*Correspondence: Jianquan Zhang, ; Zhengtu Li,
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Zeng W, Tang M, Yang M, Fang G, Tang S, Zhang J. Intravenous Cyclophosphamide Therapy for Anti-IFN-γ Autoantibody-Associated Talaromyces marneffei Infection. Open Forum Infect Dis 2022; 9:ofac612. [PMID: 36519123 PMCID: PMC9745774 DOI: 10.1093/ofid/ofac612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/10/2022] [Indexed: 08/26/2023] Open
Abstract
High titers of anti-interferon-γ autoantibodies (AIGAs) are an important factor leading to persistent, relapsed, and refractory infections in HIV-negative hosts infected with Talaromyces marneffei (TM). We report 5 patients treated with pulses of high-dose intravenous cyclophosphamide (IVCY) who were followed for 2 years. Before IVCY therapy, all patients had multiple relapses, with a median (interquartile range [IQR]) of 2 (1-3) instances of relapse. The median serum AIGA titers (IQR) were 58 753 (41 203-89 605) ng/mL at diagnosis, 48 189.4 (15 537-83 375) ng/mL before IVCY therapy, and 10 721.2 (5637-13 245) ng/mL at the end of IVCY therapy (P < .05). After 3 months of follow-up, the median AIGA titers (IQR) rose gradually to 21 232.6 (9896-45 626) ng/mL, and to 37 464.2 (19 872-58 321) ng/mL at 24 months (P < .05). Five patients discontinued antimicrobial therapy within 3-12 months after completion of IVCY therapy, but only 1 patient had a relapse. In conclusion, pulses of short-term and high-dose IVCY can effectively reduce AIGA titers.
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Affiliation(s)
- Wen Zeng
- Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Mengxin Tang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Meiling Yang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Gaoneng Fang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shudan Tang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianquan Zhang
- Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, China
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10
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Huang H, Deng J, Qin C, Zhou J, Duan M. Disseminated Coinfection by Mycobacterium fortuitum and Talaromyces marneffei in a Non-HIV Case. Infect Drug Resist 2021; 14:3619-3625. [PMID: 34526784 PMCID: PMC8435476 DOI: 10.2147/idr.s316881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/19/2021] [Indexed: 12/11/2022] Open
Abstract
Background Mycobacterium fortuitum is a rapidly growing non-tuberculous mycobacterium (NTM) with weak pathogenicity. Here, we present a rare case of disseminated M. fortuitum and Talaromyces marneffei coinfection in a human immunodeficiency virus (HIV) negative patient. Case Presentation A 28-year-old female was admitted to our hospital due to 2 months of swelling of lymph nodes on the right side of her cervix, accompanied by repeated low fever for more than 1 month. Biopsy of the right cervical lymph node and endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) both suggested granulomatous inflammation. The bacterial culture and mycobacteria examination of the lesion as well as HIV antibody test were all negative. Disseminated T. marneffei infection was diagnosed by the quantitative polymerase chain reaction (qPCR) results from the blood showing 1798 copies/ul. In the meantime, treatment with amphotericin B combined with cefoxitin was administered for suspected NTM infection. However, the once-dropped fever recurred and the lymph nodes continued to swell. Metagenomics next-generation sequencing (mNGS) detection of the lymph nodes indicated M. fortuitum. After combination treatment with amphotericin B, voriconazole, linazolamide, and imipenem, the patient's body temperature returned to normal, the lymph node swelling was gradually reduced, and the lung lesion was absorbed. Conclusion We report the first case of an HIV-negative patient diagnosed with disseminated M. fortuitum and T. marneffei coinfection with nonspecific clinical manifestation, in order to heighten awareness of these infections.
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Affiliation(s)
- Hongchun Huang
- Department of Respiratory and Critical Care Medicine, Guangxi Autonomous Regional Jiangbin Hospital, Nanning, Guangxi, 530021, People's Republic of China
| | - Jingmin Deng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China
| | - Caixia Qin
- Department of Respiratory and Critical Care Medicine, Guangxi Autonomous Regional Jiangbin Hospital, Nanning, Guangxi, 530021, People's Republic of China
| | - Jianpeng Zhou
- Department of Respiratory and Critical Care Medicine, The First People's Hospital of Nanning, Nanning, Guangxi, 530022, People's Republic of China
| | - Minchao Duan
- Department of Respiratory and Critical Care Medicine, Guangxi Medical University Wuming Affiliated Hospital, Nanning, Guangxi, 530199, People's Republic of China
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11
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Chen ZM, Li ZT, Li SQ, Guan WJ, Qiu Y, Lei ZY, Zhan YQ, Zhou H, Lin S, Wang X, Li Z, Yang F, Zeng W, Lin Y, Liu J, Zhang JQ, Ye F. Clinical findings of Talaromyces marneffei infection among patients with anti-interferon-γ immunodeficiency: a prospective cohort study. BMC Infect Dis 2021; 21:587. [PMID: 34144700 PMCID: PMC8214306 DOI: 10.1186/s12879-021-06255-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/31/2022] Open
Abstract
Background Talaromyces marneffei (T. marneffei) infection has been associated with adult-onset immunodeficiency due to anti-IFN-γ autoantibodies. We aimed to investigate the clinical features of non-HIV-infected patients with T. marneffei infection in southern China. Methods Between January 2018 and September 2020, we enrolled patients with T. marneffei infection who were HIV-negative (group TM, n = 42), including anti-IFN-γ autoantibody-positive (group TMP, n = 22) and anti-IFN-γ autoantibody-negative (group TMN, n = 20) patients and healthy controls (group HC, n = 40). Anti-IFN-γ autoantibodies were detected by ELISA. Clinical characteristics and clinical laboratory parameters were recorded. Results Compared with anti-IFN-γ autoantibody-negative patients with T. marneffei infection, anti-IFN-γ autoantibody-positive patients did not have underlying respiratory disease; more frequently exhibited dissemination of systemic infections with severe pleural effusion; had higher WBC counts, C-reactive protein levels, erythrocyte sedimentation rates, and neutrophil and CD8+ T cell counts; had lower hemoglobin levels; and were more likely to have other intracellular pathogen infections. Most of these patients had poor outcomes despite standardized antimicrobial therapy. Conclusion T. marneffei-infected patients with higher anti-IFN-γ autoantibody titers have more severe disease and complex clinical conditions.
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Affiliation(s)
- Zhao-Ming Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Zheng-Tu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Shao-Qiang Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Wei-Jie Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Ye Qiu
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Zi-Ying Lei
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Yang-Qing Zhan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Hua Zhou
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, China
| | - Sheng Lin
- Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Xinni Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Zhun Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Feng Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Wen Zeng
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Ye Lin
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China
| | - Jing Liu
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Jian-Quan Zhang
- Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518000, Guangdong, China.
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, Guangzhou, 510120, China.
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12
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He L, Mei X, Lu S, Ma J, Hu Y, Mo D, Chen X, Fan R, Xi L, Xie T. Talaromyces marneffei infection in non-HIV-infected patients in mainland China. Mycoses 2021; 64:1170-1176. [PMID: 34110649 DOI: 10.1111/myc.13295] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/07/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Talaromyces marneffei, formerly known as Penicillium marneffei, is a significant emerging pathogenic fungus in Southeast Asia which can generate life-threatening systemic infections. Human immunodeficiency virus (HIV) infection is considered as the most underlying disease among systemic infections. However, infections due to T. marneffei without HIV are increasing in recent years. OBJECTIVES Research the characteristics of T. marneffei infection in non-HIV individuals in mainland China. METHODS In this study, we searched Pubmed, China National Knowledge Infrastructure (CNKI) and WanFang from inception to 31 December 2019 for studies reporting T. marneffei infection. Our research concentrates on non-HIV-infected cases and their epidemiology, clinical manifestations, laboratory findings, treatment methods and prognosis. RESULTS T. marneffei infections in non-HIV individuals are increasing. Due to frequent present with atypical symptoms, these non-HIV-infected cases were usually misdiagnosed as other diseases, containing tuberculosis (80.7%), bacterial pneumonia (20.5%), lung cancer (5.1%) or other diseases (5.1%). CONCLUSIONS T. marneffei infection in non-HIV individuals should be taken seriously. Their symptoms and signs are not typical. Accurate diagnosis and timely antifungal agent treatment is the key to the treatment for the disease.
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Affiliation(s)
- Liya He
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Dermatology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xin Mei
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sha Lu
- Department of Dermatology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianchi Ma
- Department of Dermatology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yongxuan Hu
- Department of Dermatology and Venereology, The 3rd Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Dongdong Mo
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinsheng Chen
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ruiqiang Fan
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Liyan Xi
- Department of Dermatology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Ting Xie
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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13
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Jin W, Liu J, Chen K, Shen L, Zhou Y, Wang L. Coinfection by Talaromyces marneffei and Mycobacterium abscessus in a human immunodeficiency virus-negative patient with anti-interferon-γ autoantibody: a case report. J Int Med Res 2021; 49:300060520976471. [PMID: 33435770 PMCID: PMC7809313 DOI: 10.1177/0300060520976471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Patients with anti-interferon (IFN)-γ autoantibodies have weakened immune defenses against intracellular pathogens. Because of its low incidence and non-specific symptoms, diagnosis of anti-IFN-γ autoantibody syndrome is difficult to establish during the early stages of infection. Here, we report a patient with high titers of serum anti-IFN-γ autoantibodies suffering from opportunistic infections. The patient presented with intermittent fever for 2 weeks. During his first hospitalization, he was diagnosed with Talaromyces marneffei pulmonary infection and successfully treated with antifungal therapy. However, multiple cervical lymph nodes subsequently became progressively enlarged. Mycobacterium abscessus infection was confirmed by positive cervical lymph node tissue cultures. High-titer serum anti-IFN-γ antibodies were also detected. Following anti-M. abscessus therapy, both his symptoms and lymph node lymphadenitis gradually improved. Anti-IFN-γ autoantibody syndrome should be considered in adult patients with severe opportunistic coinfections in the absence of other known risk factors.
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Affiliation(s)
- Weizhong Jin
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Jianhong Liu
- Department of Respiratory Medicine, Jinhua Guangfu Hospital, Zhejiang, P.R. China
| | - Kuang Chen
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Ling Shen
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yan Zhou
- Departments of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Nanjin Medical University, Hangzhou, Zhejiang, P.R. China
| | - Limin Wang
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China.,Departments of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Nanjin Medical University, Hangzhou, Zhejiang, P.R. China
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