A CLINICAL STUDY ON
NON-TUBERCULAR MYCOBACTERIAL INFECTION
Author: Sudhakar
Pattanaik, M.S. (ENT). Retired Professor, MKCG Medical College, Brahmapur,
Odisha, INDIA.
This study was taken
up in 1974 in the ENT department of MKCG Medical College and continuing till
date in author’s personal clinic.
Address for
correspondence:
Dr. Sudhakar
Pattanaik, Chintamani Bhawan, RC Das Lane, Kamapalli, Brahmapur.
PIN: 760004,
Odisha, INDIA.
Ph:
00-91-7381342829
FINANCIAL
DISCLOUSER
No financial
implication involved.
CONFLICT OF INTEREST
None
ORCID
ID:0000-0003-4331-8783
Abstract:
The objective of the work is to search out the root cause of the diseases;
those are of unknown etiology like sudden or progressive nerve deafness,
chronic headache, burning mouth syndrome, atrophic rhinitis, dysphagia,
hypochondria and myriads of such diseases and to find their specific treatment,
if any. Non tubercular mycobacteria (NTM) of the mycobacterial family, till
recent days, were known as nonpathogenic organisms. And so many commonly
occurring diseases, caused by them, are passed out as diseases of unknown
etiology and so no specific treatment. Now many NTM bacteria were found apathogenic
and so the diseases caused by them, the diseases of unknown etiology, are due
to be recognized. In latter part of fifties of twentieth century one disease,
indeterminate but with few leprosy symptom, was termed as ‘paucibacillary
indeterminate leprosy’ (PIL). It responds effectively to leprosy treatment.
After the advent of other strains of Mycobacterial family and finding some of
them virulent; a new change in the conception on PIL was envisaged and its
other aspects looked for.
For
this world literature was searched; the diseases, presently considered as of unknown
etiologies, were analyzed; present conceptions on their etiology scrutiniszed;
various investigations were made and the prevailing varieties of treatments given
are assessed.
The causative factor found to be the infection
with NTM in this study. The treatment with anti NTM (non tubercular
mycobacterial) drugs which includes anti leprosy drugs, anti tubercular drugs,
macroloids, quinolones and other many ones, as per sensitivity are found giving
quite successful results.
The present findings are
expected to give relief to multimillions of sufferers throughout the world. And
avenues for multiple research centers will be envisaged to search out the other
causative factors of diseases of unknown etiology.
Key words: Nontuberculous mycobacterium, NTM; paucibacillary
indeterminate leprosy, PIL; disease of unknown etiology; goiter.
Introduction:
In spite of extra ordinary achievements in the
medical science, doctors often face patients in agony with history of failure
in treatment of their malady from many other doctors - general practitioners,
specialists and the doctors of institutions of fame. Also the approach of the
patients to doctors of other systems and faith therapy, sorcery etc ends in
despair.
The present study is made on some such
diseases (many of which are symptoms or symptom-complexes considered diseases),
where no cause and hence their treatment is known. The patients feel hapless
not only for the failure to get relief from these doctors but also for unnecessary
administration of toxic medicaments or wrong surgery. A few examples of such
diseases are given below.
1.
Headache, hemicranias, vertigo, unsteady
gait, trembling fingers etc. where no cause is detectable.
2.
Aural diseases like progressive nerve
deafness, tinnitus, vertigo, intolerable aural pain, excessive itching, but
when examined, are found to have no evidence of any pathology in ear or from
referred areas. Clinical, pathological
or radio-diagnostic procedures fail to get sign of any ear disease.
3. Dysphagia in the form of
complaint of bolus or irritating foreign body in throat causing intolerable
discomfort. There is no obstruction to food and water; also nothing detected by
endoscopy or radiological examinations.
4. Diseases of mouth like
Burning-mouth syndrome (BMS), coating and hardening of tongue, oral sub mucous
fibrosis (OSF), oral leukoplakia, loss of taste. Etiologies of all these
diseases are not known.
5. Respiratory disease like un-diagnosable
irritative cough, chest pain, dyspnea etc.
6. Diseases of nose – Primary
atrophic rhinitis (PAR), frequently recurring nasal allergy, long standing common
cold, epistaxis, rhinoscleroma, liontie ossei, atrophic nasal bones, anosmia
etc.
7. Sometimes some patients
report with multiple complaints and add new ones during the course of
treatment. These patients are considered as hypochondriac - a psychiatric
manifestation where a patient imagines that he/she is suffering from some
diseases. Sometimes depressive or irritative mood prevails among long sufferers
of diseases of unknown etiology.
8. Also there is a long list of
diseases (with symptoms or syndromes) that has no etiology and naturally no specific treatment.
Could such a lot of diseases will be there
with unknown etiology when the present scientific world is equipped with far advanced
knowledge and technology? This study is taken up to search out the etiology (or
etiologies) of such diseases with clinical approaches.
The earliest attempt to find the cause of such
a disease of unknown etiology is by doctor W.H.Jopling[1] A girl suffering from macular patches in skin,
clawing of fingers and body pain could not be diagnosed by him and so he
presented it in the meeting of Royal Society of Medicine in 1958 in London.
After extensive discussions and arguments it was decided to be considered as paucibasillary
indeterminate Leprosy (PIL) and the patient got cured with anti-leprosy drug, Dapsone,
which was the only drug for this disease then. Thus a disease without leprosy
bacterium and its specific symptomatology (paucibacillar in-determinate) was
found responding to anti leprosy drugs.
Another such attempt
in record is by the author himself[2]. Primary atrophic rhinitis (PAR), a
disease with horrible stench from nose, was a disease of unknown etiology till recent
past. He found that the sign and symptom of early leprosy; as per the
definition of WHO, Geneva (1990)[3]was traceable there. Further confirmation achieved
when it was successfully treated by anti-leprosy regimen.
In some other
studies, especially during work in post graduate (P.G) curriculum, the author
found successful result in treatment of oral, aural, neural and many other
diseases; where the etiology remained unknown; by using anti-leprosy drugs as
he found evidence of PIL. He presented them in annual conferences of the
Association of Otolaryngologists of India. After due discussions, criticisms
and appreciations they were accepted. Unfortunately a presentation of one such
work on ‘diseases of unknown etiology – covering Burning Mouth Syndrome (BMS)
and allied diseases’ to a scientific journal as PIL manifestations was rejected
on peers’ review. Another journal accepted it after peers’ review but no print
in hand yet.
Subsequently the discovery
of pathogenesis of newly found NTM indicated a new direction, a logical one, to
modify the conception of PIL – the findings remaining same.
Since inception of
mankind leprosy and tuberculosis were the diseases of horror. Search for their
cause and remedy was the cherished goal of all human healers then. The success
achieved when mycobacterium leprae was discovered by G.A. Hansen in 1873[4]. It
raised hope of searching an anti leprosy drug. It was successful in 1940 when
dapsone, the first anti leprosy drug, was discovered. Afterwards the other
species of this family, like the mycobacterial tuberculosis was discovered, clearing
the path of relief from this lethal disease. Many other species of mycobacterial
family came to limelight then but they were found nonpathogenic. Only in subsequent
years, since botanist Ernest Runyon in 1959 found out that many of these
species of mycobacterium (other than leprosy and tuberculosis) are pathogenic;
a sea-change was noted. They were called non-tubercular mycobacteria (NTM) and
were found that a lot many of them are virulent. The leprosy bacterium is also
a non-tubercular mycobacterium (NTM) but a lot of study is made and effective
treatment discovered as its fearful virulence was long known as a catastrophe
for humanity.
The finding of NTM and
its pathogenecity brought out a lot of astounding facts like their omnipresence
- in land, water and air; their infection causing diseases involving lungs,
skin, nerves, bones, lymph nodes and other disseminated diseases[5,6,7]. So
it is now in active consideration. The disease known as PIL was considered to
be the manifestation of leprosy at the time of its origin. But now it may be
proved otherwise to leprosy as absence of leprosy bacillus (paucibacillary),
non-presence of specific signs or symptoms of leprosy (in-determinate),
non-confirmation of Coch’s postulation etc. Response to antileprosy drugs was
the only criteria to accept it as a form of leprosy. The response to anti-leprosy drugs is
possible as many other NTM bacteria, being of same family, might have similar
sensitivity to anti-leprosy drugs and may produce some of the cardinal signs of
leprosy.
Many diseases or
symptom complexes (those we frequently called diseases) as discussed earlier –
may be suspected to be of NTM infection. The number of these bacteria is large.
Presently (1915) their number is about 150, and so the diseases produced by
them, singly or in combination, are expected to be numerous. Such a big number
of diseases, until now, are considered as diseases of unknown etiology and so
without specific treatment.
One glaring example
is found in the cohort study ‘Interventions for treating burning mouth syndrome [8]. All the
literatures on the treatment of burning mouth syndrome (BMS), based on
presumptive etiology like hormonal deficiency or mal-function, disturbances in
endo-lymphatic flow, genetically acquired conditions, auto-immune diseases,
anti oxidant problems and infection of newer microbes, are taken in to
consideration in planning different treatments for such diseases. The results were
almost always negative. Similar finding in a cohort study involving PobMed/ MedLine/ Cochrane
together found no success on use of different materials and methods like Acu-puncture, cognitive therapy and
drugs like clonazepam, capicin etc. in past 15 years[9] to treat BMS.
The present study is made to find the
etiology of this disease BMS (and many other ones already enumerated) which are
of unknown etiology. Papers on such diseases had been presented in the annual
conferences of Otolaryngological Society of India.
Since these agonizing
and incurable diseases are very common, doctors in practice find them frequently
in their clinic. They would get good chances to prove the actuality of the
results clinically.
Most sign symptoms,
found common to different diseases of NTM infection might be due to their
common family (leprosy or tuberculosis) origin. Accordingly they are called
paraleprosy or paratuberculosis[10]. Their other symptomatologies are specific
to their individual species. When, in a patient, more such species infect
together there occurs multiple manifestations (shaping a different diseases).
This type of multiple infections is liable to cause diagnostic problems.
Common symptomatologies
diagnostic of NTM infection are mentioned in subsequent discussions.
Literature review:
The coining of the abbreviation (PIL) is
already discussed. For assessing the clinical features in diagnosis of PIL (till
now considered to be earlier form of leprosy) we have to refer the REPORT OF
THE CONSULTAION ON THE EARLY DIAGNOSIS OF LEPROSY, Geneva (1990) of World
Health Organization[3].This report was on ‘The clinical and histopathological
aspects of early diagnosis of leprosy’. So the relevant portion in it is quoted
bellow.
“Definitions,
The following definitions are
recommended in relation to diagnosis of leprosy
·
Cardinal signs: they include a. single or multiple hypo pigmented or
erythematous lesions not typical of other skin diseases; b. loss of sensation (thermal, pain and/ or touch) with or without
a skin lesion; and c. enlarged
nerve, either trunk or Cutaneous. The other recommendations are:-
·
Suspect leprosy: Leprosy should be
suspected if only one cardinal sign of leprosy is present.
x x x x x x x
For diagnosis of early leprosy the WHO
recommends the following:
“The aim to
diagnose leprosy as soon as two cardinal features are present
·
Clinical diagnosis
On the clinical side
there is room for improvement by standardization of sensory testing to increase
reproducibility.”
x x x x x x
Coming to the present study a change is envisaged
in the diagnosis of early leprosy as depicted in the guide lines of WHO[3]. Also
after advent of the pathogenicity of nontuberculous mycobacteria (NTM), there
occurs a need to change the present nomenclature of ‘paucibacillar
indeterminate leprosy (PIL) - Paucibacillar
(no bacilli) might be the absence of Mycobacterium leprae but its substitution
with a strain of NTM, especially of paraleprotic ones, which are expected to
have a few characters of leprosy, can’t be ruled out.
Leprosy is
known to be a disease of ectodermal (skin and nerve) tissue of germinal layers.
Some of
the mycobacteria, recently proved pathogen and manifesting neurological and
skin symptomatologies, are expected to have a few characteristics of leprosy.
However a clear cut
distinction between early leprosy and infection with other strains of NTM,
having some common characteristic of it (leprosy), is not yet established.
Some ENT
and other diseases (or symptom complexes), not responding to any treatment, are
targeted for this study, and included when preliminary examination indicates
the presence of neuro-cutaneus features. A patient, in agony, being hopeless
and helpless for finding no relief from other doctors, never disagrees to
accept a new approach for treatment and it’s out-come.
The present work
may be considered as a randomized clinical work on NTM that would add and help
the organized research taken up in different centers of the world.
A patient disheartened from many
other human-healers may seek help from new ones. The new doctor after checking
his records, if he finds the disease is of unknown etiology then searching for
NTM is obligatory.
For this following
Diagnostic criteria are needed to be followed. They are:
Neurological symptomatologies:
(i)
Neural signs:
Thickness
and tenderness or both of a nerve or a small segment of it is required to be
ascertained by palpation.
A nerve is palpable only at the site where
it crosses a bone at its bare area.
Examples:
- Radial nerve in the radial groove of humerus
bone and next when it passes to the dorsum of hand above the wrist joint.
-Ulnar nerve behind the elbow joint at the
groove formed by the medial epicondyle of the humerus and olecranon of ulna
-Lateral popliteal branch of sciatic nerve
(common peronial nerve) when it crosses the neck of fibula.
-
Auricular temporal nerve which passes upwards at the neck of mandible
and the posterior root of zygoma. Mouth needs half opened to locate the neck of
mandible.
- Supra-orbital, trochlear, infra orbital
nerves may sometimes be palpable and tender indicating neuralgia in their name.
More frequently they are considered as the sign of sinusitis, ophthalmoplegia,
burning eyes or headache.
(ii). Skin Anaesthesia:
- Anaesthetic areas are detected at peripheral
regions like hand, especially at finger tips, borders of palm and interphalangeal
joints; feet (especially areas of ankle joints), dorsum of feet and toes
- Sometimes
lone depigmented or black localized patches are found in different parts of
body. Some of them may be anesthetic or hyperaphic.
(iii).pain:
- Painful localized skin patches in one or
different parts of body might be there.
- Otalgia and
itching ear (lasting and worrisome) without any pathology in ear or from its
referred areas.
-Temporary
or persisting painful nerve segments appearing around joints (periarthritis) which
is mistaken frequently, as joint pain or arthritis.
-
Burning sensation in mouth (BMS), similar sensation in ear, eyes, gum or on
different localized areas of body,
(iv). Disordered Nerve function.
- Trembling of fingers, toes or other local
areas of body and trembling of tongue (flutter) are found frequently. Spasm of
single or group of muscles, sometimes very painful, is reported. Temporary
spasmodic contractions (bending) of one or more fingers or toes are found
frequently, more so when a grip is continued for a long time. Painful spasmodic
contraction of calf muscle, especially disturbing sleep at night is a frequent
find.
- Nerve deafness – its cause, diagnosis
and treatment are world problems. Presence of other neurological signs,
discussed above, helps fixing its diagnosis.
(v). Psychic manifestations:
Patients manifesting symptoms like
irritative mood or depression are frequent. Instead of ascertaining it from the patients it should be confirmed from
their close associates.
(vi). Cutaneous manifestations:
- In addition to anesthesia, burning pain, discussed as neurological
symptoms above, skin discoloration and other changes like black or white patches
frequently found in different parts of body. The sites are at skin of back of
elbow joints, ankle joints, knee joints and interphalangeal joints. There may
be circum-orbital blackening and black keratodermic patches at the areas of
sites of pressure points at work of occupation as at lateral malleolus or elbow
joint as in photos.
(Photo no 1)
Skin
patches
(Photo no. 2).
Erythmatus,
pale white patches or leucodermic patches on skin, frequently in inter
phalangial and nail bed areas.
(Photo no. 3)
Excess hair
on limbs.
(Photo no. 4).
Alopecia of
limbs
The diagnosis by culture and
sensitivity of NTM is not followed in
this study as authorities agree that the bacteria is ubiquitous to the
environment and may represent contamination rather than actual isolate[5,11]. Moreover
laboratory facilities in India are scarce.
Materials and methods:
Selection of patients:
Patients of ENT diseases and others who
are found to have no or unsatisfactory relief from specialists and other doctors are only taken
up for this study – as indicated earlier. Those who approach first time are given
the prevailing treatment - antiallergics, antibiotics, analgesics,
vasodilators, anti-vertigo (cinnarizine, betahistine), antimigrain (flunarizine
hcl, sumatriptan, ergotamine preparations), corticosteroids, vitamins, hormones
etc for a period of one or two months according to response. Failure cases or
cases getting temporary relief with recurrence are considered for inclusion in
the study.
- Assessment of complaints:
It is frequently difficult.
Patients usually have multiple symptoms but only one (or two) complaint which
is agonizing and make him eager and anxious to get relief, is presented. Their failure
in getting relief from their agony from their previous doctors has made them
scared. So they suspect that further addition of symptoms may dilute the
torture of the presenting complaint to hamper their relief. On persistent
and inquisitive enquiry the other complaints and their durations are revealed.
The complaints, of these patients are noted carefully. The patient may
forget its duration and characters which may be there since long. It is
observed that many symptoms are frequently occurring together or differently.
-
History :
Their personal history of addiction to tobacco,
betel-nut in any form is essential as they precipitate pain, ulcer in “burning
mouth syndrome', 'submucosal fibrosis of mouth’ and leukoplakia of tongue and
cheek. Family history, of contact with leprosy and AIDS etc is ascertained.
- Clinical
examinations:
Besides a glimpse on general health,
examination of the organs involved is carried out.
For
example, in a case of Otalgia clinical examination of anatomy and physiology (Hearing
and equilibrium) is assessed. Similarly in case of headache or vertigo
examination for sinusitis, eye infections, intracranial diseases, migraine, Meniere’s
disease and other systemic diseases causing headache are explored. Usually they
were found that such treatments are exhaustively used by their previous
doctors.
The purpose of this study is to try to explore
the real causes of diseases (or symptoms
complexes considered as diseases) of unknown etiology. And so PIL which is
without specific cause and symptomatology (no or rarely found bacteria and no
definite clinical feature) is brought in to consideration.
- Testing of Skin anesthesia and temperature
perception:
A piece of cotton 20 to 30 fibers spreading is
used to test anesthesia of skin. The fibers are gently touched or lightly rubbed
on skin. This test is a controversial one as the skin of a laborer is less
sensitive and rugged while that of a child or a delicate girl is tender and
sensitive. But this is the standard followed in this study considering exceptions.
Similarly testing for hot and cold is done by two test-tubes – one with water 50
below normal body temperature (320 c) and the other with warm water
(+5) at 42o c is used. The patient is asked to indicate the
difference if any when touched to different sites – specially the sites of anesthesia.
Sometime
somewhere in the body, a small area of anesthesia or hyperesthesia is found
(patient may complain local burning or painful areas). And on palpation
thickening or tenderness of nerve in that patch of skin may be found.
-
Testing Nerve thickening and tenderness:
The easily identifiable nerves as discussed (radial,
ulnar and lateral popliteal) are palpated for thickening and tenderness. Other
nerves of face, eyes, nose and ear are detectable when they are thickened or
tender – that needs differentiation from sinusitis or otalgia of known etiology.
- Other considerations:
Atrophic
rhinitis, burning mouth syndrome, oral sub mucous fibrosis, rhinoscleroma, goiter,
arthritis etc. were the disease unsuspected of NTM infection or (PIL) until now.
When the presence of neurological or other
signs of NTM is found with these diseases the diagnosis of NTM infection, as
the causative factor, is considered. A good response to treatment of NTM in
these diseases is also a confirmatory proof. In fact many other diseases of
bone deformities like liontiasis, cervical or lumbar spondilitis, and atrophy
(figure no 12 & 13) of nasal bones are found as NTM infection.
Also epistaxis, prolonged
pyrexia, laryngeal paralysis, facial palsy and many other unexpected diseases
[12,13] come under the suspected diagnosis of NTM infections when neurological and
other signs of NTM are detected.
Management
of the cases:
Many drugs like azithromycin, clarithromycin,
ciprofloxacin, rifampicin, ethambutol, hansepran etc are found effective
against these bacteria[6]. In our study azithromycin with the MDT (rifampicin,
hansepran and dapsone, the drugs satisfactorily used in early leprosy) is used. Variations and modifications
according to patient’s tolerance are
done. For alleviation of symptoms like pain, headache, vertigo, depression or
anxiety analgesics, anti-depressants or tranquilizers are given. Initial and
subsequent pathobiochemical tests of peripheral blood and liver and kidney
function test are done before starting the treatment. In cases where prolong
treatment is required, regular such checkup is required.
It is worth noting
that the para-leprotic variety of NTM infection is considered mostly in this
study.
The result:-
A
lot of diseases (or symptom complexes), related or unrelated to each other, are
found in infections of NTM family. The number of these bacteria (the pathogenic
ones), since discovered, are found increasing. Also they cause various defects
and varieties of manifestations. To select remedy (drugs) acting on one or
other or on many of them together, present a stupendous task. Since the number
of diseases is vast detailed discussion of individual ones is beyond the scope
of this paper.
Few results of treatment of diseases of
NTM infection is presented in photographs
Photo no-5 hoto no- 6
Oral sub mucous
fibrosis with burning mouth syndrome (OSF with BSF)
Photo no -7
Geographic
tongue.
Photo no-8 Photo-9
Colloidal goiter cured
Photo no - 10
Hashimoto’s disease cured.
Photo no-11
Skin patch disappears
Photo no - 12
Cure of liontiasis ossei.
Photo no-13
Cure of nasal bone atrophy
Discussion:
The diseases where the causative
factors are not identified are “disease of unknown etiology” and hence they are
without specific remedy. Frequently insubstantial etiology leads to disastrous
consequences. One such case is primary atrophic rhinitis. Roominess of nasal
cavities is considered as its cause and so narrowing of nasal cavities by
surgical approach is in practice as a method of treatment. The surgery, usually
a must due to failure of medicinal treatment, had not only proved unsuccessful
but also leaves a memory of torture that hardly blood and bone can bear. A beautiful
girl (usually girls are suffering more from this disease) having bad smell
(stench) from nose gets defiled face as an outcome of such surgery.
Summary
Many people throughout the world are suffering
from diseases of unknown etiology and hence without specific treatment. NTM bacteria which are considered innocuous
till late found to be pathogenic and are responsible for diseases which were
considered to be of unknown etiology. The present study throws lights on
diagnosis and effective treatment of these diseases.
- - - o - - - -
Reference:
No 1. W. H Joplling’s demonstration of a case in
the meeting of Royal Society of medicine. Dec, 1958; 52: 8-9
No 2. Pattanaik. S. Interesting observations on Primary atrophic
rhinitis. Indian Journal of Otolaryngology and Head and Neck Surgery. 2006; vol. 58: No.3, July-September 264-267.
No 3. WHO. Report of consultation on the early
diagnosis of leprosy. Geneva 23- 25 May 1990. WHO/CTD/LEP 90.2: 11-12
No 4. Irgans L.M. The discovery of Mycobacterium
Leprae. A medical achievement in the light of evolving scientific methods. Am J
Dermatopathol1984 Aug; 6(4):337-43
No 5 .
Griffith DE, Aksamit T, Brown- Elliott BA, Catanzaro A, Daley C, Gordin
F, Holland SM, et el. An Official ATS/IDSA statement: diagnosis, treatment and
prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med.
2007; 175: 367-416
No 6. Katoch VM. Infections due to non-tuberculous
mycobacterial (NTM). Indian J Med Res 2004 Oct; 120 (4): 290-304.
No 7. Iseman MD, Buschman DL, Ackerson LM. Pectus
excavatum and scoliosis. Thoracic anomalies associated with pulmonary disease
caused by Mycobacterium avium complex. Am Rev Respir Dis 1991; 144: 914-6
No 8.
Zakrzewska JM, Forssell H, Glenny AM Interventions for the treatment of burning
mouth syndrome. Cochrane Database Syst Rev. 2005 ;25( 1): CD002779.
No 9.
Iraen Miziara, Aziz Chaquary, Cumalia Vargah. Theraputic Option in Idiopathic
Burning Mouth Syndrome: Literature Review. 2015 Jan; 19(1): 86 – 89.
No 10. Mc Fadden JJ, Butcher PD, Chiodini R,
Herman – Taylor J. Crohn’s disease
related mycobacteria are identical to mycobacterium
paratuberculosis as determined by 26as
DNA probes that distinguish between mycobacteria species. J Clin Microbiol
1987; 25: 796 – 801.
No 11. Falkinham JO., 3rd Nontuberculous mycobacteria
in environment. Clin Chest Med. 2002; 23:
529 – 551
No 12. P.N. Jervis, J.A. Lee and P.D.Bull. Management of non-tuberculous
mycobacterial persistent ladenitis in children: the Sheffield Otolaryngology
experience. Clin – Otolaryngol Allied Sci. 2001 June; (3):243-248.
No 13.
O. Shamriz, D. Engelhard, A. P. Rajs, H.Kaidar-Shwartz, J.-L. Casanova, and
D.Averbuch “Mycobacterium szulgai chronic multifocal osteomyelitis in an
adolescent with inherited STATI deficiency,” Pediatric Infectious Disease
Journal 2013 vol. 32: no. 12, 1345 –
47.
END
Comments
Post a Comment