• • • •

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Interesting Infectious Disease Cases Presentation

~..I ,,-..I "oil -"_'1 ... "_'1 ' oil ° ~,..I ... "ll'lnallUnlUlUUna~m~IIYtnUtl6NulU Unl'U\,l~lflNulUIIVla~'lUtl6V11'WI\,l~lallnll

, ~ JC ° '" " ,,'" " ..I "JC 1' , ii' 1 " " oilfttll tl1tJ~'I~an1' uuYtnUN'fl1l1IIa~N IflUl'U6~'I~tltll~ 1111~~ 1 \,l \,l~1\,ltll111tlflVl6~\1'6• •• . . • , ~ co 1 '" ... ",,,, , oil ,... ,~ ~

tll111n11'~ \,lfll"fl1l1YtUltJ1a II a~nn lft~U~fll1 tl6ftl111UflYt'6~N~Ytal~V1H' C)f~tll1

1"iI ... , "...,...... " " "_'1'"~~ ~I \,lUnl'U\,lllflIlYtnu IYt6'IJ1U'lJlmla~lIflft1111nfl'Un'1I1\,l'U6~NulU'lU6\,l

, ..

Anemia, Thrombocytopenia, Prolonged Fever with Persistent Pseudomonas eeruqinose Septicemia

"lllrJ1'Yl[J 'lff~ HN 311189 mrJ 25 tI 1l3J~lL'U.1ff3Jm-I 1 \J 1 I

ff1m -nlth:::3J"Yi~"'VI1~llLf\~ 11.JiJ1rJ3JH1nh "VirJ11.J1~LLV:"wit" I I I \J I

Yi~"'VI1~llLnq] L!ltl1WYi 17 5jt1'U.1rJ'U. Vi.fl. 2527 ~f1m1tl"L~tl~tltln "" '

~13J1"w'U.LL~:::ii~1q]13J"'13J1 1 L~tl'U.

~tl1m~ 3Jii~~ L~tl~tltln 9113.1"'1 ~1 L;jrJ1~11tJ LL~::: L~tl~tltl n \J I 1 ...

q]13J1,.w'U. L!ltl 1 L~tl'U. ntl'U.1~'VI1'V13Jtl ~'U.LL ~:::fi'U.rJ1~'U. 13J~;j'U. qJtl

3.11 L~ 3Jiitrffff11::: dJ'U.L ~tl~LL~:::tl ~ ~l,.:::"Il ~ ,,1tJ'fl.Jnwi'n ');o1~ , '

h "Vi£.J11.J1mLv:"wit"\'U.~"'VI1~1lLn91 1~'fl.Jm,,1it~d'rJ-htl'U. ldio­"

pathic thrombocytopenic purpura LLqlJ!tl"LLl!lnhflleukemia

~~m,.m1~L~tl~Vil.J~3J11q]mq]24% L:ij~L~tl~'lJ1119.000/~1.J.3J3J.

it11q]"Yl~ 83% M3J1Ylfl'm'i 17% LVi~'YlL~'Yl 13.920/~1.J.1I3J.

L~1:::1'lJm:::'JnVil.J myeloid hyperplasia with esinophilia,

adequate megakaryocytes 1~~ prednisolone 60 3Jn./1'U. ."

LL~::: \~L~tl~'lJm:;tlrih "Vi£.J11.J1~LL v:"ii'U.~t11rJii1,j 37.8-40°"ll. 1~ " "

'fl.Jm,,1n');o1~1rJ ampicillin LLqI~t11[Jmm,.13J~~'U. oit~fI" LLfI::: . I \J I I

LVi~rJ ~"'lJtliJ1rJ3J1'fn');o1;;m"L'YlVi,,) ejJ,,1~tJ,.:::1lL~3JL~3J-h ~t11rJ , ," .. 1" '" .. °.1 .. .~U~L~ "tl'U.L'lJ1'V1f1tl~Lfltl~m3J1lJ":::3J1nL3-4 L~tl'U. ,LL~:::LYl"'VIrJ~

,

u~Lrlm,j1h "Vi£.J11.J1~~~"'VI1~1lLf\91 "

nlUI119;HnltJ1l1ni'u m13J~'\.Ll.~tl~ 110/60 3J3J.tJ,.tl'Yl

-nVi~1: 140 fl~"/'U.1;; 'VI1rJh'VItll.J 40 fl~"/'U.1;; qnL'VIlJii 38.3°"ll.

~l'V1Un 64 nn. ff" 160"ll3J. ff~~ Li\'U.1~ oit~3J1n L'VI~il" "

L~mrtlrJ LL~:::eltl'U.LVi~rJ ~1'V1u"ii petechiae LL~::: purpuric

spots ~1 i 1tJ "'1.J191 4 "ll3J. \J!"lllrJ1m" ~3J L3JL~l.J ~13Jfl~1 13JVil.J qJtl3J~lL 'VI~tl,,13J1q] 13JVil.J"tlrJu~£.J1m3JLL'lJ'U. 'lJ113J1.J13J

":::1.Jl.J~'U.tJn~ LL~:::91"1~m"'Yl11"'VIUnVil.J melena

" _I ... ..,..; '" Nafll,ml~nl\3\16~unUVlfll'II'fl1U

Hb 4.9 gm%. Hot 12%. ~C 15.700/~1.J.iJ3J •• PMN

83%. Lymph 17%. platelet UtlrJ3J1n. trffff11:::tJn~. q~~l":::

occult blood:- positive, BUN 16mg%. creatinine 0.6mg%.

155

::'Jod 1 o1lJvlJod 3156 1111 H 11 n. fl. n;tI. 25270

Na 146mEq/L, K 4.5 mEq/L, Cl 113mEq/L. CO 2 32

mEq/L, bilirubin 1.5 mg%. direct bilirubin 0.5 mg%.

alkaline phosphatase 55 IU, SGOT 46 units, SGPT 73

units, total protein 5.1 gm%. albumin 2.5 gm%. prothrom­

bin time 12.4 sec. (control 13.0see.), malarial smear nega­

tive, HBsAg negative, Direct Coomb test negative, 1rlYl

~,tJ1,j~tlfl'lij faint nodular lesion in both lungs possibly

metastatic lesions. EKG: sinus tachycardia

"'.1 ( <1... '" '" <1emma lI~l'1U'YIty~'j::'VfVn'Hu t'l'lU1WlU)

~t11tJdltJdiji1tl!'VI1L~el'lflel n~I1J~";I'V\'Il',j~1 i.tl L1JU pete­

chiae LLt'l:: purpura ijb~el'leleln~l1Ji.d~ULLt'l::~ltJir;),;)ld::~~1

~11i~'l";huH::Ltlui1tl!'VIlm,j md~d1,;)~ peripheralh'JL~fl'l

blood smear ';)::'ll1tJ1ii';)utJi.~1Jln 1U~t11tJdltJdYlU11Lii~L~fl~ u

LL~,jii hypochromia 2+ anisocytosis bbt'l:: poikilocytosis 1+

ii fragmented cells LLt'l:: polychromasia Ul,j bii'lL~el~'ill1

LYl1J~U lhu1'V1tYLtiU polymorphonuclear bni'lL~el'l"eltJ1Jln ';)uLLl1m::hFwu Lt'ltJ~11ibbtJn aplastic anemia elelni.tli.~ LLfl

,;)::~el,jLLtJn,;)ln h'J Idiopathic thrombocytopenic purpura

(ITP) LLt'l:: leukemia 1u ITP Lii~L~fl'lbb'l,jiTntln~bbt'l::~t11tJ

L~el'li.~hN LLfl1u~t11tJdltJdii~ltJel,;),;)ld::~l LLt'l::i1~~ 11:: iiL ~el~ u ,

~,j~11i~t11tJ-n'li.~ md~d1';)i."lJm::~n~u1Iii erythroid hy­

perplasia ~,jLtlumd~elU~Uel,jflelmdL~tJL~el~ granulopoiesis

use lymphopoiesis tln~ hl~u blast cells ~,jLLtJn leukemia

i.~ megakaryocytes LYl1J~u1ui."lJm::~n ~,j~~tli.~11~t11tJ dltJdiimd~I t'lltJ Lni'l L~el'lU eln '1.'ilm::~n ';)ui.ll~u Lni 'l L~el'l Lt'ltJ

u

UH::LtlU immunologic destruction 'il1';)';)lntJl'VI1el';)ln ITP

i.llUl,;)::Ltlu,;)lnm1::~~L~el mdvel1Ji.'ilm::'lni.ll~uiron pig­

ment LL~'l\l1ILtlu1m::ydfl,jL'VI~n,;)lnmdL~utJL~el'l~,jff1ul'VItl!

elelnm,jL~Um'VIld Ueln,;)ln~IL'VI~'Yl1,j h'JL~el'lLL~1~el,j'VII~IL 'VI~, , ~u~~llii1L~fl'leleln'YlI,jL~U'il1'V1ld~1tJ ~,ji.~dltJm~1,jffm::o LYn::'il1'V1ldi.ll~uml1J~~tln~ LL t'l:: ffel,jn ~el ,j'lm::LYn::m'VIld

u

~U11ii super £icial hemorrhagic gastritis ~~tlmd1ii';)utJ

11~t11tJLtlu ITP u

1:h'Vl'tUi1tl!'VI1~-n'IU ~u1~ LLt'l::L~,",Jl'tJii"lJel,j91u~'ltln~L~n

"eltJ i.~~d1,;) HBsAg LLt'l:: direct Coomb test i.~~t'lt'lU ~l

ultrasonogram "lJel,j~1JLLt'l::rlel~l~tln~ LLfl~U1Iiil1J1<;)L~n"eltJ ~ ,j'J~li.lli.~,;)lnmdm1';)1NmtJ

i1tlJ'VI1~i.lli.~LtlUL'VI <;)1i~t11tJ1Jl h ,j~tJlUIt'l LLflY;U111JTlU., , u

LLt'l::ijml1Jth~tlJ ~el i.if ~ ,j~U11'V1~'l1ui.1iji.if'Yln1U elm'VIl1i:J .., , , \J

el~d::'VI";h,j 37.8-38.9'an • Lriflel~h ,j~tJ1Ult'l~~,j'Vl'1'l11Ln<;)<;)d1,;) u \J 1J

i1~~11::~ULii~L~el~'il11~IU1U1Jln i.~1m;'I~1tJ ampicillin

i.if~,jel~d::tJ::'VI~,jLL~1~U~,jBn LrielVltJ1Jlh ,j~tJ1UI~di.~tld::~ u u

LYl1JL~1J11~t11tJQ'lLv h{iUL,j''V1~el'lL~el'l~I1J' 3-4 L~elU use u

bYl,j'VItJ'lLrieli.ll~UltJ'J~,jd md<;)d1';)mYl~,tJ1 ,j~tlel'lij~nlt m::, 'VI~el1Je)m~U"lJU1'lL~n i m::';)ltJ ~lli~ ,j"tJ1H::ij septicemia

,;)lnmdQ'lLvh{iULiil'V1t'lel'lL~el~~1 LLt'l::elHii endocarditis ~,j

i.~ff,jLYll::L~el,;)lm~el'l'VI~ltJ'J~,j

m1fmnll,,~m1ItJ~UUlltJ"-3

luluLLdn~1ui.-nuh,jYltJ1UIt'li.~ifresh blood 4 units

~1Jl1<;)'J1~~ULtiU 27% Lni~L~el'l'll'ui.~ 6.000/t'lU.1J1J. Liiel,j

,;)lni.ffiii';)utJ";hbtlu ITP ~,jli dexamethasone 4 1Jn. Liil'VIt'lel'l

L~el'l'Yln 6 -K111J,j .,, th'VI1ui1tlJ'VI1L~el,jmd~'lL~el'VI~,j,;)lni.~LYlI:: L~el,;)lm~el'lLLt'l::i1~~11::LL~1i.~i empirical therapy 1'ltJ

mfltJ~~~'ilel,j~t11tJ~Q~bv h{iUbiil'VI~el~b~el'l~T;hul,;)::btlUb~el u ,

Staphylococcus 1JlnYi~'l ~,j1i cloxacillin 2 n11JLiil'V1t'lel~

L~el~'Yln 6 -K111J,j bbt'l::diel,j,;)ln~t11tJL'JtJ<;)d1,;)YlU1Iije)m~um,j , u

b~ui1~~11::,;)In1Jbn'l bbt'l::'VI1,j~t'l11~TlU cloxacillin ~,jli

gentamicin 80 1Jn. biil'V1t'lfl~b~el~'Y)n 8 i'111J,j111J~1tJ ~t'l

ilrmD11i.ii~l t'l,j bbfli.llt'l,j~,jd ::~utln~ 1ulu~ 5 'VI~,j1ui.l'luh,j~tJIUIt'l i.~~t'lmdbYll::b~fl,;)ln

L~el~~,j 3 "lJ1<;)~U Staphylococcus bbt'l:: Coagulase positive

~ ,ji.1fleltJI penicillin, ampicillin, oxacillin, tetracycline,

erythromycin, chloramphenicol, co-trimoxazole, gen­

tamlctnuee kanamycin ~t'lmdLv'n::L~fl,;)lni1tHn1::Ltlu E. coli 1.500.000 1'J1t'lil/1Jt'l. b~eldi.1fleltJl chloramphenicol,

nalidixic acid, co-trimoxazole, kanamycin, gentamicin

use amikacin ~,j1itJlL~1J~-\I 2 "llii~fleli.tl 'VI~,j,;)ln~litJli.tl i.~ 1 "tl~l~i.ii~It'l,j LLfli.llt'l,j~-\ltln~ ~,ji.~ff ,jL~fl~L ~1::L~el~1 {in 2 'il1~ LLt'l::ff-\li.'ilm::~mY;I::L~el~1tJ ~-\I~t'ln~U1JI'VI~,j,;)ln

u

itu 1 «tl'lI~LtluL~fl Pseudomonas aeruginosa ~,j,;)lm~el'l 2 "lJ1~LLt'l::,;)lni."lJm::'ln L~fli.1fleltJl cefoperazone, gentami­

u .,

cin, dibekacin, sisomicin, amikacin LLt'l::~fltJl carbeni­

cillin ';)ln~t'lL~1::L~el~eleln1JI~I,j,;)ln'J~,jLLdni.llLLuh1lLtiu

contamination 'VI1eli.ll ~,jL~I::L~el,;)lmi'i1J 'VIt'lfl<;)Q'ltJl LLt'l::

media ~HLY;I::L~el y;u"·:hi.llijL~fl~u LLt'l::i.~L,;)I::L~el'lLY;I:: L~el~IBn 2 'il1'l~ ,jn~ub~m~tJ1TlU i.1LLt'l::~elflfltJ1L'llUL~tJ1TlU LLfli.lli.~L~el Staphylococcus {imt'ltJ'VI~-\lmd1nltl~i.~tl ~-\I LtlU~LLUUelU11 Pseudomonas aeruginosa dLtlU~IL'VI~'ilfl,j hm1,j i i1tl!'VI11ILn,mnQ~Lv h{iu'VI1mnmlnmd1nltI1u

h ,j~tJlUlt'l~1JLn<;) 'VI1mL3JLLfl~h ,jY;tJ1UIt'lLLV;,jd LLt'l::Lrieli.ll

i.~Liiel Staphylococcus LL~1~-\li.~'VItJ~ cloxacillin use gen­, ' ,

tamicin an,j1v:1.tl 3 "tl~IV;LL~1 LLt'l::Ltl~tJULtiU amikacin 500

1Jn. Liil'VIt'lfl<;)L~el'l~I'Yln, 12 -K111J-\I 111JTlU cefsulodin 2 n11J

Liil'V1t'lel<;)L~el<;)'Yln,.6 -K111J,j i.iit'l-\l1u1U1,,j~ULLt'l:: t'l,j,;)U ~-\ltln~

J Infect Dis Antimicrob Agents

LLGl:: cefsulodin 'VI~\I~.h~~ff\l1Y;£J1L~3JrJDDfl 2 itl~1Y;LL~1~\I ~ tJ

'VIq~'VI3.I~ ~Gl"lJrJ\I MIC "lJrJ\lL~rJ Pseudomonas aeruginosa

~LL£Jflt~~lfli'\.4Yi'1hii~\I~ MIC ~rJ amikacin 3.1 t3J1mflf3J/3JGl.

gentamicin 6.2 t3J1fl'nlf3J/3JGl.

netilmicin 3.1 t3J1mflf~/3JGl. tobramycin 1.6 t3J1mflf3J/3JGl.

cefsulodin 800 t3J1fl1flf3J/3JGl.

ticarcillin 1,600 t3J1fl1flf3J/3JGl.

'VI~\I~1~~~t11£J~'lJ1£J~'!)~ iit'ii~l i ~\lYl'lJ':hdJ'\.4~lfl f111~~L~rJ~LL~Gl drain LLGl::tJ phlebitis ~Y\GlrJ~L~rJ~~1Y;~lLfl~rJ ~\I~rJ3J1t'iiGl\l~' ~t11£J''lJtl1::'Yl1'\.4m'VI11t~ LL~Yl'lJ':h~t11£Jii~m~m::

tJ • tJ

'1"'.lIllI ~ A. d f"lJrJ\lf111 b"ll~L"£J1rJ£J~ flrJ moon face, steroi acne, bu falo

hump LLGl:: proximal weakness ~\I~'il"lJ'\.41~"lJrJ\I prednisolone

Gl\l~lfl 60 3Jfl./1'\.4 LtI'\.4 45 3Jfl.j1'\.4LLGl:: 30 3Jfl./1'\.4nrJ'\.4~1'V1ti1£J

~t11£J LLGl::1y; vincristine 113J~1£J t~~1'V1ti1£J~t11£J1'\.4~1l1Yl~ tJ tJ

11mm~n1'\.4h\lYl£J1'l.J1Gl 1031'\.4 'VI3J~f1i1.i~l£Jtl1::3J1m 700,000

'lJ1'Y) ~t11£Jt~fl~'lJ3J1~~'l13J~Gl'Ylfl 2 itl~1Y;LtI'\.4nGl1 2 fl~ \lM\ItJ ,

t1fl~f1t3Jiit'ii ,l1'V1UmYl3J 3 nn. LLGl::Lfl~~L~rJ~fl\l~rJD1'\.41::~'lJ tJ

50,000-60,000/Gl'lJ.3J3J. 1~£J1y; prednisolone 30 3Jfl./1'\.4LLGl::

vineristine 2 un. L'ii1'V1GlrJ~L~rJ~'1fl 2 itl~lY; t~3JrJ'lJ~t11£J1Y;

hematologist ~LLGlf{J~l~rJttl

q_1 G "'.... QI c!emmn (ll'YfYlU'\1t1l'l':i~'YfVn'Hll 'f'I'lU1~U)

~t11£J11£J~LL£Jm~rJ~lm~rJ~t~~\1 Staphylococcus LL Gl:: tJ ,

Pseudomonas aeruginosa ']\It3J1"li contaminant uty'VIl':h

1111~~L~rJ~Ln~~'\.4~\lLL~4i''\.4~\I 2 ~1 ~lfl1111U~LlJ hD'\.4L'ii1'V1GlrJ~ ~ ~

Lf\rJ~ 'VI1m~rJ Pseudomonas Ln~;j'\.41'\.4h\lYl£J1'lJ1GlY\'VI~\I LYl11::

~t11£JrJD1'\.4 h \lYl£J1'lJ1Gl~mfi'l3J11::£J::'VI~\lLL~1 ~L;j£J'\.4iifl113JL V; '\.4 \J \J \J \J

111111~~L~rJ~tiH::Ln~~'\.4~\lLL~~'\.4~\I 2 ~1 ~1£JL'VI'l~Gl~\I~rJttl~, 1. ~t11£Jiitl1::~U~LlJ hD'\.4L'ii1'Yl1\1'V1GlrJ~Lf\rJ~i~L~'\.4LU'\.4 \J.... I ....

nGl1 3-4 L~rJ'\.4 1~£J1i,;t1t11::t11Gl::Gl1£JLlJ hD'\.4 ']\lrJH~~L~rJt~

~\I 2 ~1 ~Yl'lJtJrJ£Jfl11~rJ Staphylococcusl - 3 ~\lLtI'\.4Uty'VI1~ LLYl'Ylm'Yl£JL111~m'r'\.4f1 L~rJ~ifflt~3.11 ~lfl~1'V1,x~ \lrJHLU'\.4 Staphy­

lococcus epidermidis ri1'V1f'lJ Pseudomonas Yl'lJt~L~3JrJ

t3J1H::LtI'\.4 Pseudomonas aeruginosa 'VI1rJ~'\.4i4-6 LYl11::LU'\.4

L~rJ~rJD1'\.4,l1 ~~~ 3J£J1U~ ~ \I'ElHLU'\.4,l1t11::t11'VI1rJ,llflGlrJ\l1 tJ "

2. ~Glm1'il CBC LiimL1flfunh\lYl£Jl'lJ1Gl1'\.41,]Lfi'l113Jrl'lJ

1111 iit'ii~u'lJ~'\.4 '\.411 ii1111 ~~ L~rJ ~\lLL~ LL1 n LL3J11~t11£J 'il:: iiei'fl L~ u , tJ

'Yl1\1L~UU~~11:: LL~iht~~ \lLf\rJ~ LYl1:: L~rJ 1'\.4"lJ m::it'\.4fl1~11fl \lt~ ~ sinn LL Gl:: 'VI1fl't111111 ~l£J 1l1Yli'\Iff t1rJ~fifl \lLV;'\.4 'VIDrJ 3Jei'f1L ~ u

3. f111~~L~rJ113Jrl'\.4 2 ~1 L"li'\.4 Staphylococcus 113Jrl'lJ

Pseudomonas Ln~~'\.4t~tJrJ£J1'\.4 "addict endocarditis"7,8 1~£J

Vol. I No. 3 Jul. - Sept. 1984 159

~1'V1U\lLtI'\.4LL'VI~\lri1~tlJ~~~"lJrJ\lL~rJ~'Yh1Yi'L n~ endocarditis ~ ,

Yl'lJ11LtI'\.4L~rJ Staphylococcus ~.rl'rJ£JGl:: 60 LLGl:: Pseudomonas

frJ£JGl:: 15 "lJrJ\I~t11£J7,8 I I \J .... .......... ...

4. ff \lY\'ll1£J;1LL'\.4d1L~rJf1\1 2 ittiH::LtI'\.4L~rJ'\.4rJfl h \lYl£J1'lJ1 s

~rJ L~rJ Staphylococcus ~t1~rJ penicillin LLGl:: Pseudomonas

b~rJ gentamicin ~\lif1LtI'\.4L~rJ1'\.4h \lYl£J1'lJ1Gl~1'\.43J1fliffl'il:: ~rJ~rJ£J1L 'VI~ld LLGl::rJii'lJ1£Jt~11't11t3J~'\.4L~rJ Staphylococcus

nrJ'\.4LLGl::: ~flTh t~ ttlt~rJD1~11~L~11l1£J 1'\.4 1 itl~lY;~1Yi'£J1 LL ~::tJ L~rJ Pseudomonas ~'\.41J1fi'VItl\l ~\ltiH::~'\.4YlfrJ3Jrr'\.4Lff£JfiLL1fl 'VI1rJ111111 LYl1::L~rJ~lmf\rJ~fl~ \lLL1flt~ Staphylococcus ~LtI'\.4 LY1£J\I transient bacteremia L'Yhii'\.4 1~£Jt3Jt~LtI'\.4L~rJ~lL'VI~~, 't11h~\n~ endocarditis LLGl::L~rJt~£J14i'1'\.4~Gl;1Yl~L'VI3J1::~3J L~rJ fi'VI3J~1tI'ElD1\111~L~1 LYl11::'VI~\I'il1fl~1'~~LL~1vegetation ~ "t1ttlLYl1::L~rJfi~'\.4LYi£J\IPseudomonas ~1LfI£J1

Uty'VI1~ti1~'\.4h~fltl1'::f111'V1~\I~rJITP ~\lLU'\.4 underlying

disease "lJrJ\I~t11£J1'\.4u'il'ilU'\.4~ L11'Yl11'lJ11hfl~Ln~'il1fltl1\n1£J1 tJ' ...

fl3J3;!'\.4~\lL1£Jfl11 immunologic thrombocytopenic purpura

'VI1rJ autoimmune thrombocytopenic purpura LL'Yl'\.49,1O hfl

~Ln~~'\.4dirJ\I'il1fliiantibody ~mfl1~Lf\rJ~ LL~1't111V;Ln~iifli1 't11Gl1,£J~13J3J111 antibody ~LtI'\.4.immunoglobulinLLGl::LU'\.4

IgG LU'\.4~1'\.41'V1tl! ri1'V1f'lJ~lL'VI~~11\1111£J~f1\1immunity

"llU~~~'\.43J1 ~~11Ln~~'\.4LtirJ\I~lflT suppressor lymphocytes

't11 \11'\.4UrJ£J Gl\lrJD1 \I~~t1fl~ ~ \1m 'il L~£J1'iirJ \I'Yl1 \I~'\.41i,m13Jfit~ LtirJ\I'il1flYl'lJhfl~3J1fl1'\.4fl'\.4~ii HLA LL'lJ'lJ DRW2 LLGl::~t11£J

tJ

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J Infect Dis Antimicrob Agents

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