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Xu X, Andersson E, Rahbar A, Söderberg-Nauclér C, Nowak P. Cytomegalovirus infection among people living with HIV in Sweden: Case profiles, treatment strategies and patient outcomes at Karolinska University Hospital 2010-2020. HIV Med 2024; 25:692-699. [PMID: 38350653 DOI: 10.1111/hiv.13618] [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: 07/30/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVES In countries with access to early antiretroviral treatment (ART), opportunistic infections caused by cytomegalovirus (CMV) in people living with HIV (PLWH) are becoming increasingly rare. As potential complications are severe, it is critical to remain aware of this important diagnosis. However, clinical characteristics and prognosis of CMV infection in PLWH in the era of modern ART have not been well described. METHODS Here, we compiled the clinical presentation, management and outcome of CMV infection in PLWH treated at the infectious diseases clinic of Karolinska University Hospital during 2010-2020. RESULTS We identified 51 cases of active CMV infection, based on detection of CMV-DNA, mainly diagnosed in patients with CD4 T-cell count <200 cells/μL (86%). Median time from HIV diagnosis to detection of CMV infection was 16 days. In 20 cases (39%), CMV infection was symptomatic with retinitis identified as a manifestation in 70% of cases. Symptomatic CMV infection was treated for 73 (20-313) days upon diagnosis, mostly using valganciclovir. One-year mortality was 22% and was associated with longer time to ART initiation from HIV diagnosis and with comorbidities, but not with CMV-DNA levels or CD4 count. Immune reconstitution was not significantly compromised in patients with symptomatic CMV, although CD4/8 ratio tended to be lower in patients with systemic CMV infection. CONCLUSIONS Retinitis remains the most common manifestation of symptomatic CMV infection in PLWH. Recognizing CMV infection is important, especially in the management of 'late presenters'. Adequate duration of antiviral therapy and appropriate follow-up must be ensured to avoid complications.
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Affiliation(s)
- Xinling Xu
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Solna, Microbial Pathogenesis Unit, BioClinicum, Karolinska Institute, Stockholm, Sweden
| | - Emmi Andersson
- Department of Laboratory medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Laboratory, Stockholm, Sweden
| | - Afsar Rahbar
- Department of Medicine Solna, Microbial Pathogenesis Unit, BioClinicum, Karolinska Institute, Stockholm, Sweden
- Division of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Söderberg-Nauclér
- Department of Medicine Solna, Microbial Pathogenesis Unit, BioClinicum, Karolinska Institute, Stockholm, Sweden
- Division of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Institute of BioMedicine, Unit of Infection and Immunology, MediCity Research Laboratory, Flagship InFLAMES, Turku University, Turku, Finland
| | - Piotr Nowak
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Infectious Diseases, Karolinska Institute, Stockholm, Sweden
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Sattwika PD, Subronto YW, Retnowulan H, Sattwika KA, Nurdiati DS. Anti-cytomegalovirus preemptive therapy to prevent cytomegalovirus disease in HIV-infected patients: a systematic review. Infect Dis (Lond) 2023; 55:221-233. [PMID: 36630310 DOI: 10.1080/23744235.2023.2165708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND HIV patients are at higher risk of contracting and developing into an asymptomatic form of CMV infection. This review aimed to evaluate the efficacy and safety of preemptive therapy for preventing CMV disease in HIV patients. METHODS The electronic search was conducted in MEDLINE/PubMed and CENTRAL from inception until 9 September 2022. Studies were included if they assessed the efficacy or safety of anti-CMV preemptive therapy compared to placebo or no therapy. Risk of bias were assessed using the Cochrane Risk of Bias tool for randomized trials version 2 or the Cochrane Collaboration Risk of Bias in Non-randomized Studies of Interventions. The random-effects model was used to calculate effect sizes. RESULTS We identified six RCTs (2135 participants) and four observational studies (395 participants), with five RCTs were performed before highly active antiretroviral therapy (HAART) era. Preemptive therapy did not reduce the incidence of CMV disease (RR 0.84, 95% CI: 0.59-1.18), yet reduced the RR of all-cause mortality rate by 26% (RR 0.85, 95% CI: 0.74-0.97) with a low quality of evidence. The incidence of neutropenia as an adverse event increased significantly (RR 2.47, 95% CI: 1.12-5.45) with moderate quality of evidence. CONCLUSIONS With the advent of HAART, a limited number of studies have been performed to explore anti-CMV preemptive therapy due to the improved outcomes of HIV patients with CMV viremia. Therefore, optimal HAART should take precedence over anti-CMV preemptive therapy. The protocol for this review was registered in the Prospective Register of Systematic Reviews (CRD42020145765).
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Affiliation(s)
- Prenali Dwisthi Sattwika
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia.,Clinical Epidemiology and Biostatistics Unit, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Yanri Wijayanti Subronto
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia.,The Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Heni Retnowulan
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia.,Clinical Epidemiology and Biostatistics Unit, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | | | - Detty Siti Nurdiati
- Clinical Epidemiology and Biostatistics Unit, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia.,Department of Obstetrics and Gynecology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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3
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Ueckermann V, Janse van Rensburg L, Pannell N, Ehlers M. Characteristics and outcomes of patients admitted to a tertiary academic hospital in Pretoria with HIV and severe pneumonia: a retrospective cohort study. BMC Infect Dis 2022; 22:548. [PMID: 35705920 PMCID: PMC9202192 DOI: 10.1186/s12879-022-07522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) contributes significantly to morbidity and mortality in South Africa. Pneumonia and opportunistic infections remain a major cause for hospital admission among those living with HIV, even in the era of the widespread availability of antiretroviral therapy. METHODS In this retrospective cohort study, the records of patients admitted with HIV and severe pneumonia, requiring high care/intensive care admission, during a period of 12 months (February 2018 to January 2019) were reviewed. Demographic details, antiretroviral use, HIV viral load, CD4 count, sputum culture results and radiological imaging of patients were recorded. Data was analysed to determine variables associated with mortality. RESULTS One hundred and seventeen patient records were reviewed for this study. The patients were young (mean age 38.3 years), had advanced disease with low CD4 counts (mean 120.2 cells/mm3) and high HIV viral loads (mean 594,973.7 copies/mL). Only 36.9% (42/117) were on highly active antiretroviral therapy (HAART) on presentation to the hospital. Mycobacterium tuberculosis (M. tuberculosis) was found to be the cause for pneumonia in 35% (41/117), whilst Pneumocystis jirovecii (P. jirovecii) was found in 21.4% (25/117). Bacterial pneumonia was the cause in 17.1% (20/117) of patients while no specific aetiology was found in 26.6% (31/117) of patients in the cohort. Mortality among the cohort studied was high (40.1%) and the average length of stay in hospital in excess of two weeks. The need for ICU admission, ventilation and CMV viremia was associated with increased mortality. Chest X-ray findings did not correlate with the aetiology of pneumonia, but multiple B-lines on lung ultrasound correlated with P. jirovecii as an aetiology and there was a signal that pleural effusion with fibrin stranding predicts tuberculosis. CONCLUSIONS Patients studied presented with advanced HIV and were often naïve to antiretroviral therapy. Mortality in this cohort of young patients was high, which emphasis the need for earlier diagnosis and treatment of HIV at a primary care level. Lung ultrasound may have clinical utility in the management of patients with HIV and pneumonia, particularly to diagnose P. jirovecii as an aetiology.
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Affiliation(s)
- Veronica Ueckermann
- Department of Internal Medicine, University of Pretoria, Pretoria, South Africa.
| | | | - Nicolette Pannell
- Department of Internal Medicine, University of Pretoria, Pretoria, South Africa
| | - Marthie Ehlers
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
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4
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Tian B, Sun J, Bai J, Zhang R, Liu J, Shen Y, Li C, Liu L, Chen J, Qi T, Lu H. Cytomegalovirus viremia is associated with poor outcomes in AIDS patients with disseminated nontuberculous mycobacterial disease. Biosci Trends 2021; 15:406-412. [PMID: 34588390 DOI: 10.5582/bst.2021.01279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both cytomegalovirus (CMV) viremia and disseminated nontuberculous mycobacterial (NTM) disease are common opportunistic infections in AIDS patients. Whether concurrent CMV viremia is associated with mortality in patients with AIDS and disseminated NTM disease is unknown. Subjects were patients with AIDS and disseminated NTM disease seen at a single center from January 2015 to April 2021. Data were retrospectively collected. Differences in demographics and clinical characteristics and hospitalization survival rates were compared between patients with disseminated NTM and with CMV viremia or not. Subjects were 113 AIDS patients with disseminated NTM who were seen at this Hospital from January 2015 to April 2021. Twenty-six of the patients had CMV viremia and 87 did not. The median age was 36 years (interquartile range [IQR] 29-42) and 108 patients were male (96%). The median CD4 count was 7 cells/µL (IQR 3-17). The median plasma CMV viral load was 9,245 IU/mL (IQR 3147-45725). The serum albumin of patients with CMV viremia was significantly lower than that of patients without CMV viremia (P = 0.03). Compared to patients without CMV viremia (81.6%), patients with CMV viremia had a significantly poorer prognosis (P = 0.01). Cox regression analysis indicated that the risk of a poor prognosis in patients with CMV viremia was 4.7 times higher than that in patients without CMV viremia (P = 0.003), and patients with CD8 more than 250/μL had a better prognosis (P = 0.02). CMV viremia increases the risk of a poor prognosis in patients with AIDS and a disseminated NTM infection. A routine CMV DNA test should be performed on patients with AIDS and disseminated NTM disease in order to reduce the risk of death.
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Affiliation(s)
- Bo Tian
- Department of Infectious Disease, The Third People's Hospital of Kunming, Kunming, Yunnan, China
| | - Jianjun Sun
- Department of Infectious Disease, The Third People's Hospital of Kunming, Kunming, Yunnan, China
| | - Jinsong Bai
- Department of Infectious Disease, The Third People's Hospital of Kunming, Kunming, Yunnan, China
| | - Renfang Zhang
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
| | - Jun Liu
- Department of Infectious Disease, The Third People's Hospital of Kunming, Kunming, Yunnan, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
| | - Chongxi Li
- Department of Infectious Disease, The Third People's Hospital of Kunming, Kunming, Yunnan, China
| | - Li Liu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
| | - Jun Chen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
| | - Tangkai Qi
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
| | - Hongzhou Lu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Shanghai, China
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5
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Wang Y, Lin X, Li Y, Wen Y. Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report. Medicine (Baltimore) 2021; 100:e26605. [PMID: 34260544 PMCID: PMC8284711 DOI: 10.1097/md.0000000000026605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention. PATIENT CONCERNS A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain. DIAGNOSES The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing. INTERVENTIONS The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed. OUTCOMES The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery. LESSONS Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xuyong Lin
- Pathology Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuji Li
- Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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6
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Tang S, Zhao N, Wang LY, Wen Y. Frosted branch angiitis due to cytomegalovirus-associated unmasking immune reconstitution inflammatory syndrome: a case report and literature review. BMC Infect Dis 2021; 21:613. [PMID: 34174839 PMCID: PMC8236202 DOI: 10.1186/s12879-021-06311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 06/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background Cytomegalovirus (CMV) retinitis is a common opportunistic infection in patients with acquired immunodeficiency syndrome. The common funduscopic manifestations are haemorrhagic necrotising variety and granular variety. Frosted branch angiitis (FBA), as a special form, when it occurred after antiretroviral therapy(ART), could possibly be associated with immune reconstitution. We report a case of FBA secondary to CMV infection-associated unmasking immune reconstitution inflammatory syndrome (IRIS). Case presentation A 27-year-old man with human immunodeficiency virus infection developed FBA after 35 days of ART. The left Aqueous humour (AqH) tested positive for CMV DNA, and the patient was diagnosed with CMV retinitis. The degree of intraocular inflammation was reflected by increased levels of interleukin (IL)-6 and IL-8 in AqH. After anti-CMV treatment and continuous ART for several months, his FBA and vision significantly improved. CMV DNA became undetectable in the left AqH, and the IL-6 and IL-8 levels in AqH decreased. Conclusion FBA could be a sign of CMV-associated unmasking IRIS. Anti-CMV treatment alone or combination with steroid treatment may be administered, depending on the changes in CMV DNA load and immunologic profile of AqH.
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Affiliation(s)
- Shi Tang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China
| | - Ning Zhao
- Department of Ophthalmology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Li Yang Wang
- Department of Gastroenterology, The sixth People's Hospital of Shenyang, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China.
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7
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Kiros M, Geteneh A, Andualem H, Alemu D, Tesfaye A, Tefera DA, Mihret A, Alemayehu DH, Mulu A. Human cytomegalovirus infection among treatment-naive HIV-1 infected patients in Ethiopia. PLoS One 2021; 16:e0247264. [PMID: 33600457 PMCID: PMC7891702 DOI: 10.1371/journal.pone.0247264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/03/2021] [Indexed: 11/19/2022] Open
Abstract
Subclinical human cytomegalovirus (HCMV) replication is associated with immune dysfunction in immuno-suppressed antiretroviral therapy (ART) naive HIV infected individuals. No data is documented in Ethiopia so far concerning HCMV co-infection among HIV infected individuals. Hence, this study was aimed at generating data regarding the prevalence of active HCMV infection among treatment-naive HIV-infected individuals from Ethiopia. For this purpose, we enrolled 97 treatment-naive HIV infected study subjects in Addis Ababa from June to December 2018. ELISA and conventional PCR were performed consecutively to detect HCMV specific IgM antibody and HCMV DNA respectively. Of the 97 study subjects, 12 (12.4%) were positive for anti-CMV IgM antibodies but were not confirmed by PCR. With regard to the PCR positivity, 4/97 (4.1%) samples were positive for HCMV DNA. No statically significant associations were found between the dependent and independent variables. The presence of HCMV DNA in the current study highlights the need for a routine laboratory diagnosis for preventing HCMV disease among HIV-infected individuals early. Besides, the use of anti-CMV therapy for these CMV viremic individuals is also recommended as this can reduce the burden of CMV complications and consecutively prolonging the life of HIV infected individuals.
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Affiliation(s)
- Mulugeta Kiros
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- * E-mail:
| | - Alene Geteneh
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Henok Andualem
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Derbie Alemu
- Department of Medical Laboratory Sciences, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | | | | | - Adane Mihret
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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Bastos-Oreiro M, Balsalobre P, Miralles P, Berenguer J, Dorado N, Bailen R, Obreoscoa G, Anguita J, Serrano D, Díez-Martín JL, Kwon M. Autologous stem cell transplantation for lymphoma in HIV+ patients: higher rate of infections compared with non-HIV lymphoma. Bone Marrow Transplant 2020; 55:1716-1725. [PMID: 32132653 DOI: 10.1038/s41409-020-0846-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 12/21/2022]
Abstract
Autologous hematopoietic stem cell transplantation (ASCT) is a well-established treatment strategy in HIV-related lymphoma patients (HIV+ Ly). Nevertheless, current evidence is mainly based on reports from specialized centers, multicentre heterogeneous studies, noncomparative analyses, or registry data-based comparisons. Likewise, the risk of infections reported so far for this population, seems to be similar to that of HIV- patients, and it does not seem to impact on mortality. We report a single-center retrospective comparative analysis of AHCT procedural results, infectious complications and survival in HIV+ Ly matched with a non-HIV comparative cohort. Thirty-three HIV+ patients and 45 matched controls, who underwent ASCT between 2000 and 2016, were included. Transplant-related toxicity, event-free survival, relapse rate, and overall survival were similar in both groups. Engraftment was delayed in HIV+ Ly (neutrophils: 15 vs 12 days (p = 0.0001), and platelets 39 vs 16 days (p = 0.00001)). Bacterial infections during the pre-engraftment period were more frequent in HIV+ Ly (RR 2.24, p = 0.017), as well as viral infections in the postengraftment period (RR 3.22, p = 0.004). CMV reactivation was more frequent in HIV+ Ly (39% vs 15% p = 0.007). In conclusion, ASCT is viable and effective in HIV+ Ly, but it is associated with a higher risk of infection.
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Affiliation(s)
- Mariana Bastos-Oreiro
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Gregorio Marañón Health Research Institute, Madrid, Spain.
| | - Pascual Balsalobre
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Pilar Miralles
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Berenguer
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nieves Dorado
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Rebeca Bailen
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Gillen Obreoscoa
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier Anguita
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - David Serrano
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Luis Díez-Martín
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Mi Kwon
- Haematology and Haemotherapy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
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