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Michel C, Echahidi F, Place S, Filippin L, Colombie V, Yin N, Martiny D, Vandenberg O, Piérard D, Hallin M. From Investigating a Case of Cellulitis to Exploring Nosocomial Infection Control of ST1 Legionella pneumophila Using Genomic Approaches. Microorganisms 2024; 12:857. [PMID: 38792686 PMCID: PMC11123157 DOI: 10.3390/microorganisms12050857] [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: 03/28/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 05/26/2024] Open
Abstract
Legionella pneumophila can cause a large panel of symptoms besides the classic pneumonia presentation. Here we present a case of fatal nosocomial cellulitis in an immunocompromised patient followed, a year later, by a second case of Legionnaires' disease in the same ward. While the first case was easily assumed as nosocomial based on the date of symptom onset, the second case required clear typing results to be assigned either as nosocomial and related to the same environmental source as the first case, or community acquired. To untangle this specific question, we applied core-genome multilocus typing (MLST), whole-genome single nucleotide polymorphism and whole-genome MLST methods to a collection of 36 Belgian and 41 international sequence-type 1 (ST1) isolates using both thresholds recommended in the literature and tailored threshold based on local epidemiological data. Based on the thresholds applied to cluster isolates together, the three methods gave different results and no firm conclusion about the nosocomial setting of the second case could been drawn. Our data highlight that despite promising results in the study of outbreaks and for large-scale epidemiological investigations, next-generation sequencing typing methods applied to ST1 outbreak investigation still need standardization regarding both wet-lab protocols and bioinformatics. A deeper evaluation of the L. pneumophila evolutionary clock is also required to increase our understanding of genomic differences between isolates sampled during a clinical infection and in the environment.
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Affiliation(s)
- Charlotte Michel
- Department of Microbiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
- Department of Microbiology, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Rue Haute 322, 1000 Brussels, Belgium
| | - Fedoua Echahidi
- Department of Microbiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Sammy Place
- Department of Internal Medicine and Infectious Diseases, EpiCURA Hospital, 7301 Hornu, Belgium
| | - Lorenzo Filippin
- Department of Internal Medicine and Infectious Diseases, EpiCURA Hospital, 7301 Hornu, Belgium
| | - Vincent Colombie
- Department of Internal Medicine and Infectious Diseases, EpiCURA Hospital, 7301 Hornu, Belgium
| | - Nicolas Yin
- Department of Microbiology, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Rue Haute 322, 1000 Brussels, Belgium
| | - Delphine Martiny
- Department of Microbiology, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Rue Haute 322, 1000 Brussels, Belgium
- Faculty of Medicine and Pharmacy, Mons University, Chemin du Champ de Mars 37, 7000 Mons, Belgium
| | - Olivier Vandenberg
- Innovation and Business Development Unit, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Rue Haute 322, 1000 Brussels, Belgium
- Centre for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Avenue Roosevelt 50, 1050 Brussels, Belgium
| | - Denis Piérard
- Department of Microbiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Marie Hallin
- Centre for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Avenue Roosevelt 50, 1050 Brussels, Belgium
- European Plotkin Institute for Vaccinology (EPIV), Université Libre de Bruxelles (ULB), Avenue Roosevelt 50, 1050 Brussels, Belgium
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Buultjens AH, Vandelannoote K, Mercoulia K, Ballard S, Sloggett C, Howden BP, Seemann T, Stinear TP. High performance Legionella pneumophila source attribution using genomics-based machine learning classification. Appl Environ Microbiol 2024; 90:e0129223. [PMID: 38289130 PMCID: PMC10952463 DOI: 10.1128/aem.01292-23] [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: 08/09/2023] [Accepted: 11/30/2023] [Indexed: 02/08/2024] Open
Abstract
Fundamental to effective Legionnaires' disease outbreak control is the ability to rapidly identify the environmental source(s) of the causative agent, Legionella pneumophila. Genomics has revolutionized pathogen surveillance, but L. pneumophila has a complex ecology and population structure that can limit source inference based on standard core genome phylogenetics. Here, we present a powerful machine learning approach that assigns the geographical source of Legionnaires' disease outbreaks more accurately than current core genome comparisons. Models were developed upon 534 L. pneumophila genome sequences, including 149 genomes linked to 20 previously reported Legionnaires' disease outbreaks through detailed case investigations. Our classification models were developed in a cross-validation framework using only environmental L. pneumophila genomes. Assignments of clinical isolate geographic origins demonstrated high predictive sensitivity and specificity of the models, with no false positives or false negatives for 13 out of 20 outbreak groups, despite the presence of within-outbreak polyclonal population structure. Analysis of the same 534-genome panel with a conventional phylogenomic tree and a core genome multi-locus sequence type allelic distance-based classification approach revealed that our machine learning method had the highest overall classification performance-agreement with epidemiological information. Our multivariate statistical learning approach maximizes the use of genomic variation data and is thus well-suited for supporting Legionnaires' disease outbreak investigations.IMPORTANCEIdentifying the sources of Legionnaires' disease outbreaks is crucial for effective control. Current genomic methods, while useful, often fall short due to the complex ecology and population structure of Legionella pneumophila, the causative agent. Our study introduces a high-performing machine learning approach for more accurate geographical source attribution of Legionnaires' disease outbreaks. Developed using cross-validation on environmental L. pneumophila genomes, our models demonstrate excellent predictive sensitivity and specificity. Importantly, this new approach outperforms traditional methods like phylogenomic trees and core genome multi-locus sequence typing, proving more efficient at leveraging genomic variation data to infer outbreak sources. Our machine learning algorithms, harnessing both core and accessory genomic variation, offer significant promise in public health settings. By enabling rapid and precise source identification in Legionnaires' disease outbreaks, such approaches have the potential to expedite intervention efforts and curtail disease transmission.
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Affiliation(s)
- Andrew H. Buultjens
- Department of Microbiology and Immunology, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Center for Pathogen Genomics, University of Melbourne, Melbourne, Victoria, Australia
| | - Koen Vandelannoote
- Bacterial Phylogenomics Group, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Karolina Mercoulia
- Department of Microbiology and Immunology, Microbiology Diagnostic Unit, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Ballard
- Department of Microbiology and Immunology, Microbiology Diagnostic Unit, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Clare Sloggett
- Department of Microbiology and Immunology, Microbiology Diagnostic Unit, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin P. Howden
- Center for Pathogen Genomics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Microbiology and Immunology, Microbiology Diagnostic Unit, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Torsten Seemann
- Department of Microbiology and Immunology, Microbiology Diagnostic Unit, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy P. Stinear
- Department of Microbiology and Immunology, Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Center for Pathogen Genomics, University of Melbourne, Melbourne, Victoria, Australia
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3
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Krøvel AV, Hetland MAK, Bernhoff E, Bjørheim AS, Soma MA, Löhr IH. Long-read sequencing for reliably calling the mompS allele in Legionella pneumophila sequence-based typing. Front Cell Infect Microbiol 2023; 13:1176182. [PMID: 37256104 PMCID: PMC10226664 DOI: 10.3389/fcimb.2023.1176182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/21/2023] [Indexed: 06/01/2023] Open
Abstract
Sequence-based typing (SBT) of Legionella pneumophila is a valuable tool in epidemiological studies and outbreak investigations of Legionnaires' disease. In the L. pneumophila SBT scheme, mompS2 is one of seven genes that determine the sequence type (ST). The Legionella genome typically contains two copies of mompS (mompS1 and mompS2). When they are non-identical it can be challenging to determine the mompS2 allele, and subsequently the ST, from Illumina short-reads. In our collection of 233 L. pneumophila genomes, there were 62 STs, 18 of which carried non-identical mompS copies. Using short-reads, the mompS2 allele was misassembled or untypeable in several STs. Genomes belonging to ST154 and ST574, which carried mompS1 allele 7 and mompS2 allele 15, were assigned an incorrect mompS2 allele and/or mompS gene copy number when short-read assembled. For other isolates, mainly those carrying non-identical mompS copies, short-read assemblers occasionally failed to resolve the structure of the mompS-region, also resulting in untypeability from the short-read data. In this study, we wanted to understand the challenges we observed with calling the mompS2 allele from short-reads, assess if other short-read methods were able to resolve the mompS-region, and investigate the possibility of using long-reads to obtain the mompS alleles, and thereby perform L. pneumophila SBT from long-reads only. We found that the choice of short-read assembler had a major impact on resolving the mompS-region and thus SBT from short-reads, but no method consistently solved the mompS2 allele. By using Oxford Nanopore Technology (ONT) sequencing together with Trycycler and Medaka for long-read assembly and polishing we were able to resolve the mompS copies and correctly identify the mompS2 allele, in accordance with Sanger sequencing/EQA results for all tested isolates (n=35). The remaining six genes of the SBT profile could also be determined from the ONT-only reads. The STs called from ONT-only assemblies were also consistent with hybrid-assemblies of Illumina and ONT reads. We therefore propose ONT sequencing as an alternative method to perform L. pneumophila SBT to overcome the mompS challenge observed with short-reads. To facilitate this, we have developed ONTmompS (https://github.com/marithetland/ONTmompS), an in silico approach to determine L. pneumophila ST from long-read or hybrid assemblies.
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Affiliation(s)
- Anne Vatland Krøvel
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- National Reference Laboratory for Legionella, Stavanger University Hospital, Stavanger, Norway
| | - Marit A. K. Hetland
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- Department of Biological Sciences, Faculty of Mathematics and Natural Sciences, University of Bergen, Bergen, Norway
| | - Eva Bernhoff
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- National Reference Laboratory for Legionella, Stavanger University Hospital, Stavanger, Norway
| | - Anna Steensen Bjørheim
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- National Reference Laboratory for Legionella, Stavanger University Hospital, Stavanger, Norway
| | - Markus André Soma
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | - Iren H. Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
- National Reference Laboratory for Legionella, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Klatt AB, Diersing C, Lippmann J, Mayer-Lambertz S, Stegmann F, Fischer S, Caesar S, Fiocca Vernengo F, Hönzke K, Hocke AC, Ruland J, Witzenrath M, Lepenies B, Opitz B. CLEC12A Binds to Legionella pneumophila but Has No Impact on the Host's Antibacterial Response. Int J Mol Sci 2023; 24:ijms24043891. [PMID: 36835297 PMCID: PMC9967056 DOI: 10.3390/ijms24043891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 02/17/2023] Open
Abstract
Legionella pneumophila is an intracellular pathogen that can cause severe pneumonia after the inhalation of contaminated aerosols and replication in alveolar macrophages. Several pattern recognition receptors (PRRs) have been identified that contribute to the recognition of L. pneumophila by the innate immune system. However, the function of the C-type lectin receptors (CLRs), which are mainly expressed by macrophages and other myeloid cells, remains largely unexplored. Here, we used a library of CLR-Fc fusion proteins to search for CLRs that can bind the bacterium and identified the specific binding of CLEC12A to L. pneumophila. Subsequent infection experiments in human and murine macrophages, however, did not provide evidence for a substantial role of CLEC12A in controlling innate immune responses to the bacterium. Consistently, antibacterial and inflammatory responses to Legionella lung infection were not significantly influenced by CLEC12A deficiency. Collectively, CLEC12A is able to bind to L. pneumophila-derived ligands but does not appear to play a major role in the innate defense against L. pneumophila.
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Affiliation(s)
- Ann-Brit Klatt
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Christina Diersing
- Institute for Immunology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Juliane Lippmann
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- Max Planck Institute for Infection Biology, Vector Biology, 10117 Berlin, Germany
| | - Sabine Mayer-Lambertz
- Institute for Immunology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Felix Stegmann
- Institute for Immunology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Swantje Fischer
- Institute for Immunology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Sandra Caesar
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Facundo Fiocca Vernengo
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Katja Hönzke
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg University of Technology Cottbus—Senftenberg, 03046 Cottbus, Germany
| | - Andreas C. Hocke
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- German Center for Lung Research (DZL), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Jürgen Ruland
- Institute of Clinical Chemistry and Pathobiochemistry, School of Medicine, Technical University of Munich, 80333 Munich, Germany
- Center for Translational Cancer Research (TranslaTUM), 81675 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
- German Research Center (DKFZ), 69120 Heidelberg, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, 17493 Greifswald, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- German Center for Lung Research (DZL), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Bernd Lepenies
- Institute for Immunology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
- Correspondence: (B.L.); (B.O.)
| | - Bastian Opitz
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
- German Center for Lung Research (DZL), Augustenburger Platz 1, 13353 Berlin, Germany
- Correspondence: (B.L.); (B.O.)
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Svetlicic E, Jaén-Luchoro D, Klobucar RS, Jers C, Kazazic S, Franjevic D, Klobucar G, Shelton BG, Mijakovic I. Genomic characterization and assessment of pathogenic potential of Legionella spp. isolates from environmental monitoring. Front Microbiol 2023; 13:1091964. [PMID: 36713227 PMCID: PMC9879626 DOI: 10.3389/fmicb.2022.1091964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Several species in the genus Legionella are known to cause an acute pneumonia when the aerosols containing the bacteria from man-made water systems are inhaled. The disease is usually caused by Legionella pneumophila, but other species have been implicated in the infection. The disease is frequently manifested as an outbreak, which means several people are affected when exposed to the common source of Legionella contamination. Therefor environmental surveillance which includes isolation and identification of Legionella is performed routinely. However, usually no molecular or genome-based methods are employed in further characterization of the isolates during routine environmental monitoring. During several years of such monitoring, isolates from different geographical locations were collected and 39 of them were sequenced by hybrid de novo approach utilizing short and long sequencing reads. In addition, the isolates were typed by standard culture and MALDI-TOF method. The sequencing reads were assembled and annotated to produce high-quality genomes. By employing discriminatory genome typing, four potential new species in the Legionella genus were identified, which are yet to be biochemically and morphologically characterized. Moreover, functional annotations concerning virulence and antimicrobial resistance were performed on the sequenced genomes. The study contributes to the knowledge on little-known non-pneumophila species present in man-made water systems and establishes support for future genetic relatedness studies as well as understanding of their pathogenic potential.
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Affiliation(s)
- Ema Svetlicic
- Novo Nordisk Foundation Center for Biosustainability, Kongens Lyngby, Denmark
| | - Daniel Jaén-Luchoro
- Department of Infectious Diseases (Sahlgrenska Academy) at the University of Gothenburg, Gothenburg, Sweden
| | | | - Carsten Jers
- Novo Nordisk Foundation Center for Biosustainability, Kongens Lyngby, Denmark
| | - Snjezana Kazazic
- Laboratory for Mass Spectrometry and Functional Proteomics, Ruder Boskovic Institute, Zagreb, Croatia
| | - Damjan Franjevic
- Division of Zoology, Department of Biology, Faculty of Science, University of Zagreb, Zagreb, Croatia
| | - Goran Klobucar
- Division of Zoology, Department of Biology, Faculty of Science, University of Zagreb, Zagreb, Croatia
| | | | - Ivan Mijakovic
- Novo Nordisk Foundation Center for Biosustainability, Kongens Lyngby, Denmark,Systems and Synthetic Biology Division, Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden,*Correspondence: Ivan Mijakovic,
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Iliadi V, Staykova J, Iliadis S, Konstantinidou I, Sivykh P, Romanidou G, Vardikov DF, Cassimos D, Konstantinidis TG. Legionella pneumophila: The Journey from the Environment to the Blood. J Clin Med 2022; 11:jcm11206126. [PMID: 36294446 PMCID: PMC9605555 DOI: 10.3390/jcm11206126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/26/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
An outbreak of a potentially fatal form of pneumonia in 1976 and in the annual convention of the American Legion was the first time that Legionella spp. was identified. Thereafter, the term Legionnaires’ disease (LD) was established. The infection in humans is transmitted by the inhalation of aerosols that contain the microorganisms that belong to the Legionellaceae family and the genus Legionella. The genus Legionella contains genetically heterogeneous species and serogroups. The Legionella pneumophila serogroup 1 (Lp1) is the most often detected strain in outbreaks of LD. The pathogenesis of LD infection initiates with the attachment of the bacterial cells to the host cells, and subsequent intracellular replication. Following invasion, Legionella spp. activates its virulence mechanisms: generation of specific compartments of Legionella-containing vacuole (LCV), and expression of genes that encode a type IV secretion system (T4SS) for the translocation of proteins. The ability of L. pneumophila to transmigrate across the lung’s epithelium barrier leads to bacteremia, spread, and invasion of many organs with subsequent manifestations, complications, and septic shock. The clinical manifestations of LD depend on the bacterial load in the aerosol, the virulence factors, and the immune status of the patient. The infection has two distinct forms: the non- pneumatic form or Pontiac fever, which is a milder febrile flu-like illness, and LD, a more severe form, which includes pneumonia. In addition, the extrapulmonary involvement of LD can include heart, brain, abdomen, and joints.
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Affiliation(s)
- Valeria Iliadi
- Izhevsk State Medical Academy, Kommunarov Street 281, 426034 Izhevsk, Russia
| | - Jeni Staykova
- Faculty of Public Health, Medical University of Sofia, Byalo More Str. 8, 1527 Sofia, Bulgaria
| | - Sergios Iliadis
- Izhevsk State Medical Academy, Kommunarov Street 281, 426034 Izhevsk, Russia
| | | | - Polina Sivykh
- State Budgetary Health City Polyclinic No 2 (GBUZ GB2) of Krasnodar, Seleznev Street 4/10, 350059 Krasnodar, Russia
| | - Gioulia Romanidou
- Nephrology Department, General Hospital “Sismanogleio”, 69100 Komotini, Greece
| | - Daniil F. Vardikov
- Russian Research Center for Radiology and Surgical Technologies of the Ministry of Health of the Russian Federation, Tkachey Str. 70-16, 192029 St. Petersburg, Russia
| | - Dimitrios Cassimos
- Pediatric Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Theocharis G. Konstantinidis
- Blood Transfusion Center, University General Hospital of Alexandroupolis Dragana Campus, 68100 Alexandroupolis, Greece
- Correspondence: ; Tel.: +30-2551-352005
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