scholarly journals A retrospective study of clinical and laboratory features and treatment on cats highly suspected of feline infectious peritonitis in Wuhan, China

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Yiya Yin ◽  
Ting Li ◽  
Chaohao Wang ◽  
Xiaoya Liu ◽  
Hehao Ouyang ◽  
...  

AbstractFeline infectious peritonitis (FIP) is a systemic, potentially fatal viral disease. The objectives of this study were to review clinical and laboratory features and treatment of cats highly suspected of FIP in Wuhan, China. The clinical records of 127 cats highly suspected of FIP were reviewed for history, clinical signs, physical findings, and diagnostic test results. Sex, neutering status, breed, age, and month of onset of disease were compared with the characteristics of the clinic population. Age and neutering status were significantly correlated with FIP-suspicion. Sex, breed and onset month were not associated with FIP. There were many more FIP-suspected cases in cats in young cats or male intact cats. Effusion was observed in 85.8% of the FIP-suspected cats. Increased serum amyloid A (SAA) and lymphopenia were common laboratory abnormalities in the FIP cases. Furthermore, 91.7% of the cats highly suspected of FIP had an albumin/globulin (A/G) ratio < 0.6, while 85.3% had an A/G ratio < 0.5. The mortality rate for FIP-suspected cats was 67%, and six submitted cases were confirmed by FIP-specific immunohistochemistry. Of the 30 cats treated with GS-441524 and/or GC376, 29 were clinically cured. The study highlights the diverse range of clinical manifestations by clinicians in diagnosing this potentially fatal disease. A/G ratio and SAA were of higher diagnostic value. GS-441524 and GC376 were efficient for the treatment of FIP-suspected cats.

2021 ◽  
Author(s):  
Masato Katayama ◽  
Yukina Uemura

Abstract Background: Feline infectious peritonitis (FIP) is a fatal disease caused by feline coronavirus or its mutated pathogen designated as FIP virus. The most common form of FIP is wet or effusive, with non- regenerative anemia and clinical signs of mainly non-specific, such as recurrent fever, anorexia and weight loss. Recently, promising results using new anti-viral drug for treating cats with FIP were observed, but identification of rescuable FIP has been still challenging. It is highly worth to identify infected cats possible to be saved by such an anti-viral agent.Methods: At the initial veterinarian’s examination, owner inquiry-based signalments, viral gene detection by PCR and representative laboratory tests for diagnosis of FIP including hematocrit, A to G ratio, total bilirubin, serum amyloid-A and α1-acid globulin of 141 cats with effusive FIP were compared with those of 28 non-FIP disease cats. Consequently, 116 of them were rescued by administration of anti-viral drug Mutian X and the residual 25 were deceased unfortunately under treatments. Clinical and laboratory indicators observed prior to initial medication were also evaluated statistically between survived and non-survived groups.Results: Expectedly, levels for a few items of signalments (appetitive and activity scores), hematocrit, A to G ratio, total bilirubin, serum amyloid-A, α1-acid globulin and viral gene were found to be distributed distinctively between 141 FIP and 28 non-FIP cats. In the comparison between survived and non-survived FIP cats, most of their parameters including levels for hematocrit, A to G ratio, serum amyloid-A, α1-acid globulin and viral gene were not statistically different. Interestingly, total bilirubin concentrations of survived FIP cats were declined significantly than those of non-survived, and similarly, body temperatures, appetitive and activity scores appeared to be higher probably in accordance with their physical condition.Conclusions: Several clinical and laboratory indicators were informative in diagnosis of effusive FIP. We have investigated that one of the quantitative markers, total bilirubin levels, tend to be distributed characteristically in rescuable cats with effusive FIP. Elevated levels of total bilirubin may be a prognostic risk factor for severe FIP, predicting no clinical benefit obtained by using Mutian X as a therapeutic agent.


2021 ◽  
pp. 1-8
Author(s):  
Aviv Segev ◽  
Ehtesham Iqbal ◽  
Theresa A. McDonagh ◽  
Cecilia Casetta ◽  
Ebenezer Oloyede ◽  
...  

Background Clozapine is associated with increased risk of myocarditis. However, many common side-effects of clozapine overlap with the clinical manifestations of myocarditis. As a result, there is uncertainty about which signs, symptoms and investigations are important in distinguishing myocarditis from benign adverse effects of clozapine. Clarity on this issue is important, since missing a diagnosis of myocarditis or discontinuing clozapine unnecessarily may both have devastating consequences. Aims To examine the clinical characteristics of clozapine-induced myocarditis and to identify which signs and symptoms distinguish true myocarditis from other clozapine adverse effects. Method A retrospective analysis of the record database for 247 621 patients was performed. A natural language processing algorithm identified the instances of patients in which myocarditis was suspected. The anonymised case notes for the patients of each suspected instance were then manually examined, and those whose instances were ambiguous were referred for an independent assessment by up to three cardiologists. Patients with suspected instances were classified as having confirmed myocarditis, myocarditis ruled out or undetermined. Results Of 254 instances in 228 patients with suspected myocarditis, 11.4% (n = 29 instances) were confirmed as probable myocarditis. Troponin and C-reactive protein (CRP) had excellent diagnostic value (area under the curve 0.975 and 0.896, respectively), whereas tachycardia was of little diagnostic value. All confirmed instances occurred within 42 days of clozapine initiation. Conclusions Suspicion of myocarditis can lead to unnecessary discontinuation of clozapine. The ‘critical period’ for myocarditis emergence is the first 6 weeks, and clinical signs including tachycardia are of low specificity. Elevated CRP and troponin are the best markers for the need for further evaluation.


2017 ◽  
Vol 45 (1) ◽  
pp. 7
Author(s):  
Társsila Mara Vieira Ferreira ◽  
Tiago Cunha Ferreira ◽  
Fernanda Maria Aragão Ximenes Porto ◽  
Conceição Da Silva Martins ◽  
Berlamino Eugênio Lopes Neto ◽  
...  

Background: In canine leishmaniasis (CanL), infection occurs through phlebotomine vectors that inoculate the protozoan Leishmania infantum into the skin that infected macrophages and activated dendritic cells (CD). Dogs with CanL present variable clinical manifestations, being common the presence of cutaneous lesions. The aim of this study was to evaluate the expression of CD45+, CD68+ and E-cadherin+  associating the skin sentinels cells and to compare the clinical-dermatological manifestations in the skin of dogs naturally infected by L. infantum.Materials, Methods & Results: Dogs infected (n = 22) by L. infantum were divided into asymptomatic group (AD, n = 9), and symptomatic group (SD, n = 13), according criteria based on the presence or absence of skin changes. Dogs non-infected (CD, n = 5) were included as control group. Samples of skin biopsies collected from scapular region were processed by routine histology and labeled by immunohistochemistry with monoclonal antibodies against CD45+, CD68+ and E-cadherin+, and were described as none, mild, moderate and intense. SD presented keratoconjunctivitis, onychogryphose, lichenification, depigmentation, alopecia, hypotrichosis, erythematous dermatitis, exfoliative dermatitis, ulcerative dermatitis and crusted dermatitis, and the frequency these alterations was expressed as percentage. The results of hematological and biochemical parameters were analyzed by Kruskal-Wallis test followed by the Dunn’s test and expressed as mean ± standard deviation, with values P < 0.05. Leukocytosis (not significant), red blood cells, hematocrit and hemoglobin (P < 0.05), total protein serum (P < 0.05), globulins (P < 0.05), albumin and A/G ratio (P < 0.01) were altered in SD in relation to CD. Cutaneous cellular infiltration, composed by macrophages, plasma cells, lymphocytes and neutrophils, was observed in CD. There was an increase of expression of the markers in SD when compared to the other groups, as moderate CD68+ expression and L. infantum, and intense CD45+ and E-cadherin+ expressions.Discussion: Cutaneous involvement is very important in CanL, as it corresponds to where is the first interaction between the parasite and the immune system. Dermatological clinical signs, leukocytosis, anemia, globulins levels have been reported for dogs naturally infected by L. infantum. Inflammatory infiltrate was distributed at superficial and deep dermis, which was composed by mononuclear cells as macrophages, plasma cells, lymphocytes and neutrophils. To characterize the immune sentinels cells in the skin it was evaluated CD45+, CD68+ and E-cadherin+ expressions. In syntomatic dogs, our results revelead an increase of expression of these markers. CD45+ is one of the most abundant molecules expressed on the white blood cell surface in various mammals, while CD68+ is a myelomonocytic marker that seems to be retained during monocyte differentiation. In the skin, increased numbers of CD68+ are related to dendritic epidermal cells, which can be expressed as CD45+/CD1a-/HLA-DR+. DCs of the skin, particularly epidermal Langerhans cells (LCs), form networks anchored to neighboring keratinocytes via E-cadherin. Thus, CD45+, CD68+ and E-cadherin+ expressions may be related to activation of skin sentinels cells in dogs naturally infected by L. infantum. Our results indicated that CanL modify the CD45+, CD68+ and E-cadherin+ expressions, which characterize the immune sentinels cells activation that promove the recruitment the cellular infiltrate, which was composed by macrophages, plasma cells, lymphocytes and neutrophils. Thus, these informations may contribute to the follow-up of CanL progression in skin.


Viruses ◽  
2021 ◽  
Vol 13 (2) ◽  
pp. 186
Author(s):  
Sandra Felten ◽  
Kaspar Matiasek ◽  
Christian M. Leutenegger ◽  
Laura Sangl ◽  
Stephanie Herre ◽  
...  

Background: Cats with neurologic feline infectious peritonitis (FIP) are difficult to diagnose. Aim of this study was to evaluate the diagnostic value of detecting feline coronavirus (FCoV) RNA and spike (S) gene mutations in cerebrospinal fluid (CSF). Methods: The study included 30 cats with confirmed FIP (six with neurological signs) and 29 control cats (eleven with neurological signs) with other diseases resulting in similar clinical signs. CSF was tested for FCoV RNA by 7b-RT-qPCR in all cats. In RT-qPCR-positive cases, S-RT-qPCR was additionally performed to identify spike gene mutations. Results: Nine cats with FIP (9/30, 30%), but none of the control cats were positive for FCoV RNA in CSF. Sensitivity of 7b-RT-qPCR in CSF was higher for cats with neurological FIP (83.3%; 95% confidence interval (95% CI) 41.8–98.9) than for cats with non-neurological FIP (16.7%; 95% CI 6.1–36.5). Spike gene mutations were rarely detected. Conclusions: FCoV RNA was frequently present in CSF of cats with neurological FIP, but only rarely in cats with non-neurological FIP. Screening for spike gene mutations did not enhance specificity in this patient group. Larger populations of cats with neurological FIP should be explored in future studies.


Author(s):  
M.M. Kiselyova ◽  
◽  
O.V. Potsiurko ◽  
A.V. Komar ◽  
N.V. Kamut ◽  
...  

Neonatal sepsis is a significant cause of mortality among newborns, especially in low and middle income countries with poor economic development. It is important to start the appropriate treatment as soon as possible, as this prevents most deaths from sepsis and reduces the occurrence of residual neurological lesions due to septic meningitis. The article provides an overview of modern literature data on the principles of diagnosis of early neonatal sepsis; mentions the main etiological factors and ways of infection by potential pathogens. Diagnostic criteria for early neonatal sepsis have been analyzed and have been classified as doubt-ful or credible. An important role is given to the assessment of potential risk factors for the development of the septic process, including data on history of pregnancy and childbirth, clinical and laboratory indicators of the baby after birth. The nonspecificity of most clinical signs of sepsis and their comparison with clinical manifestations in meningitis was carried out. The importance of the bacteriological method of detecting the pathogen in the blood, urine and cerebrospinal fluid was analyzed, which remains the «gold» standard diagnosis of neonatal sepsis, and the method of multiplex polymerase chain reaction. There is a need to detect sepsis through visual examination, such as chest radiography, computed tomography, magnetic resonance imaging and ltrasonography of the head. The diagnostic value of indicators is described with the complete blood cell count and differential, including some of its components, and markers of inflammatory process, especially the immature-to-total (I/T) neutrophil ratio, C-reactive protein, procalcitonin. The article mentions a method of determining the concentration of immunoglobulin M in the serum, the elevated level of which indicates intrauterine infection. The diagnostic value of glutathione is considered, which is a marker of the functioning of the immune system. Emphasis is placed on the expediency of using Kaiser Permanente calculator to detect signs of sepsis in the first days of a newborn's life and the choice of optimal tactics management in such patients. No conflict of interest was declared by the authors. Key words: sepsis, newborn, diagnosis of infection, neonatal.


2019 ◽  
Vol 186 (17) ◽  
pp. 563-563
Author(s):  
Cher Shi-Yee Hung ◽  
Izidora Sladakovic ◽  
Stephen J Divers

BackgroundHepatic disease in psittacine birds is common but challenging to diagnose. This retrospective study evaluates the diagnostic value of plasma biochemistry, haematology, radiography and endoscopic visualisation in psittaciforms with suspected hepatic disease that underwent endoscopic liver biopsy.MethodsClinical records of 28 companion psittaciforms from a veterinary teaching hospital (2007–2016) were reviewed. Diagnostic results were categorised as abnormal or normal and compared with histopathology for agreement or disagreement. Statistical significance was determined by kappa test for agreement and McNemar’s test for disagreement.Results11 of 28 psittaciforms (39.3 per cent) had clinical signs considered specific for liver disease. 25 of 28 (89.3 per cent) psittaciforms had histopathological liver lesions. Gross changes radiographically and endoscopically agreed with histopathology in 57.1 per cent and 53.6 per cent of cases, respectively. Aspartate aminotransferase (AST) (48.1 per cent), creatine phosphokinase (73.1 per cent) and albumin by protein electrophoresis (50 per cent) showed the highest agreement. Kappa was not significant for any parameters, while McNemar’s test for disagreement was significant for radiography, endoscopy, AST, lactate dehydrogenase, bile acid, total protein (chemistry), cholesterol, triglycerides, uric acid and glucose.ConclusionOverall, changes on plasma biochemistry, radiography or endoscopy are non-specific and do not consistently agree with histopathology results. Endoscopic liver biopsy is highly recommended if there is clinical suspicion of hepatic disease.


Author(s):  
W.L. Steffens ◽  
M.B. Ard ◽  
C.E. Greene ◽  
A. Jaggy

Canine distemper is a multisystemic contagious viral disease having a worldwide distribution, a high mortality rate, and significant central neurologic system (CNS) complications. In its systemic manifestations, it is often presumptively diagnosed on the basis of clinical signs and history. Few definitive antemortem diagnostic tests exist, and most are limited to the detection of viral antigen by immunofluorescence techniques on tissues or cytologic specimens or high immunoglobulin levels in CSF (cerebrospinal fluid). Diagnosis of CNS distemper is often unreliable due to the relatively low cell count in CSF (<50 cells/μl) and the binding of blocking immunoglobulins in CSF to cell surfaces. A more reliable and definitive test might be possible utilizing direct morphologic detection of the etiologic agent. Distemper is the canine equivalent of human measles, in that both involve a closely related member of the Paramyxoviridae, both produce mucosal inflammation, and may produce CNS complications. In humans, diagnosis of measles-induced subacute sclerosing panencephalitis is through negative stain identification of whole or incomplete viral particles in patient CSF.


Author(s):  
А.Р. Зарипова ◽  
Л.Р. Нургалиева ◽  
А.В. Тюрин ◽  
И.Р. Минниахметов ◽  
Р.И. Хусаинова

Проведено исследование гена интерферон индуцированного трансмембранного белка 5 (IFITM5) у 99 пациентов с несовершенным остеогенезом (НО) из 86 неродственных семей. НО - клинически и генетически гетерогенное наследственное заболевание соединительной ткани, основное клиническое проявление которого - множественные переломы, начиная с неонатального периода жизни, зачастую приводящие к инвалидизации с детского возраста. К основным клиническим признакам НО относятся голубые склеры, потеря слуха, аномалия дентина, повышенная ломкость костей, нарушения роста и осанки с развитием характерных инвалидизирующих деформаций костей и сопутствующих проблем, включающих дыхательные, неврологические, сердечные, почечные нарушения. НО встречается как у мужчин, так и у женщин. До сих пор не определена степень генетической гетерогенности заболевания. На сегодняшний день известно 20 генов, вовлеченных в патогенез НО, и исследователи разных стран продолжают искать новые гены. В последнее десятилетие стало известно, что аутосомно-рецессивные, аутосомно-доминантные и Х-сцепленные мутации в широком спектре генов, кодирующих белки, которые участвуют в синтезе коллагена I типа, его процессинге, секреции и посттрансляционной модификации, а также в белках, которые регулируют дифференцировку и активность костеобразующих клеток, вызывают НО. Мутации в гене IFITM5, также называемом BRIL (bone-restricted IFITM-like protein), участвующем в формировании остеобластов, приводят к развитию НО типа V. До 5% пациентов имеют НО типа V, который характеризуется образованием гиперпластического каллуса после переломов, кальцификацией межкостной мембраны предплечья и сетчатым рисунком ламелирования, наблюдаемого при гистологическом исследовании кости. В 2012 г. гетерозиготная мутация (c.-14C> T) в 5’-нетранслируемой области (UTR) гена IFITM5 была идентифицирована как основная причина НО V типа. В представленной работе проведен анализ гена IFITM5 и идентифицирована мутация c.-14C>T, возникшая de novo, у одного пациента с НО, которому впоследствии был установлен V тип заболевания. Также выявлены три известных полиморфных варианта: rs57285449; c.80G>C (p.Gly27Ala) и rs2293745; c.187-45C>T и rs755971385 c.279G>A (p.Thr93=) и один ранее не описанный вариант: c.128G>A (p.Ser43Asn) AGC>AAC (S/D), которые не являются патогенными. В статье уделяется внимание особенностям клинических проявлений НО V типа и рекомендуется определение мутации c.-14C>T в гене IFITM5 при подозрении на данную форму заболевания. A study was made of interferon-induced transmembrane protein 5 gene (IFITM5) in 99 patients with osteogenesis imperfecta (OI) from 86 unrelated families and a search for pathogenic gene variants involved in the formation of the disease phenotype. OI is a clinically and genetically heterogeneous hereditary disease of the connective tissue, the main clinical manifestation of which is multiple fractures, starting from the natal period of life, often leading to disability from childhood. The main clinical signs of OI include blue sclera, hearing loss, anomaly of dentin, increased fragility of bones, impaired growth and posture, with the development of characteristic disabling bone deformities and associated problems, including respiratory, neurological, cardiac, and renal disorders. OI occurs in both men and women. The degree of genetic heterogeneity of the disease has not yet been determined. To date, 20 genes are known to be involved in the pathogenesis of OI, and researchers from different countries continue to search for new genes. In the last decade, it has become known that autosomal recessive, autosomal dominant and X-linked mutations in a wide range of genes encoding proteins that are involved in the synthesis of type I collagen, its processing, secretion and post-translational modification, as well as in proteins that regulate the differentiation and activity of bone-forming cells cause OI. Mutations in the IFITM5 gene, also called BRIL (bone-restricted IFITM-like protein), involved in the formation of osteoblasts, lead to the development of OI type V. Up to 5% of patients have OI type V, which is characterized by the formation of a hyperplastic callus after fractures, calcification of the interosseous membrane of the forearm, and a mesh lamellar pattern observed during histological examination of the bone. In 2012, a heterozygous mutation (c.-14C> T) in the 5’-untranslated region (UTR) of the IFITM5 gene was identified as the main cause of OI type V. In the present work, the IFITM5 gene was analyzed and the de novo c.-14C> T mutation was identified in one patient with OI who was subsequently diagnosed with type V of the disease. Three known polymorphic variants were also identified: rs57285449; c.80G> C (p.Gly27Ala) and rs2293745; c.187-45C> T and rs755971385 c.279G> A (p.Thr93 =) and one previously undescribed variant: c.128G> A (p.Ser43Asn) AGC> AAC (S / D), which were not pathogenic. The article focuses on the features of the clinical manifestations of OI type V, and it is recommended to determine the c.-14C> T mutation in the IFITM5 gene if this form of the disease is suspected.


2012 ◽  
pp. 74-84
Author(s):  
Thi Kieu Nhi Nguyen

Objectives: 1. Estimating the ratios of clinical and paraclinical signs of post-term newborns hospitalized at Pediatric Department of Hue University Hospital. 2. Identifying the relation between clinical signs and paraclinical signs. Materials and Method: 72 post- term babies < 7 days of life hospitalized at NICU from 2010/5 to 2011/4. Classification of post - term newborn was based on WHO 2003: gestational age ≥ 42 weeks with clinical manifestations: desquamation on press with fingers or natural desquamation, withered or meconial umbilicus, meconial long finger nails (*) or geatational age still < 42 weeks with theses clinical manifestations (*). Data were recorded on a clinical record form. Per-protocol analysis of clinical outcomes was performed by using Medcalc 11.5 and Excell 2007. Analyses used the χ2 test or Fisher's exact test for categorical data; Student's t test was used for continuous data and the Mann-Whitney U test for nonparametric data. Data were presented as means or proportions with 95% CIs. Results: Clinical characteristics: Tachypnea and grasp were main reasons of hospitalisation (48.61%). Poor feeding, vomitting (16.67%). Asphyxia (8.34%). Jawndice (6.94%). Hypothermia < 36.50C (13.89%), fever (13.89%). Tachypnea (59.72%). Bradycardia (1.39%). Poor feeding (11.11%). Hypertonia (9.72%). Paraclinical characteristics: Erythrocytes < 4.5.1012/l (51.39%), Leucocytes 5 – 25.103/mm3 (81.94%), Thrombocytes 100- 400.103/mm3 (94.44%). Hemoglobinemia < 10mg/l (67.61%). Maternal characteristics: Menstrual cycles regular (75%). Primiparity (75%). Amniotic volume average (70.42%), little (29.58%). Aminiotic liquid clair (62.5%), aminiotic liquid yellow (4.17%), aminiotic meconial liquid (33.33%). Maternal manifestation of one of many risk factors consist of genital infection; urinary infection; fever before, during, after 3 days of birth; prolonged delivery; medical diseases influence the foetus (75%). The relation between clinical signs and paraclinical signs: There was significantly statistical difference: between gestationnal age based on obstetrical criteria and amniotic volume on ultrasound (p < 0.05); between birth weight and glucosemia p < 0.02). There was conversional correlation of average level between erythroctes number and respiratory rate (r = - 0.5158; p < 0,0001), concordance correlation of weak level betwwen leucocytes number and respiratory rate r = 0.3045; p = 0.0093). Conclusion: It should made diagnosis of postterm baby based on degree of desquamation. The mother who has menstrual cycles regular is still delivered of a postterm baby. A postterm baby has the individual clinical and paraclinical signs.


2019 ◽  
Vol 72 (8) ◽  
pp. 1437-1441
Author(s):  
Pavel Dyachenko ◽  
Igor Filchakov ◽  
Anatoly Dyachenko ◽  
Victoria Kurhanskaya

Introduction: Viral encephalitis accounts for 40-70% of all cases worldwide, central nervous system infections pose a diagnostic challenge because clinical manifestations are not typically pathognomonic for specific pathogens, and a wide range of agents can be causative. The aim: To assess the diagnostic value of intrathecal synthesis of specific antibodies in patients with inflammatory lesions of the central nervous system. Materials and methods: Within the framework of the study, two groups of 90 people in each were formed from the patients with neuroinfections admitted to our Center. Intrathecal synthesis (ITS) of total (unspecific) IgG in members of one of group (group of compare) was determined. Brain synthesis of specific antibodies (Ab) to some neurotropic pathogens (herpes simplex virus 1/2, cytomegalovirus, Epstein-Barr virus, varicella zoster virus, rubella virus, Borrelies) was studied in the second group of patients (group of interest). There were no statistically significant differences between groups by gender and age. Encephalitis and encephalomyelitis prevailed among patients of both groups Results: ITS of total IgG was established in 30 (33.3 ± 6.1 %) patients of the first group with IgG index more than 0.6 indicating on inflammatory process in CNS and no marked changes of CSF. ITS of specific Ab was determined in 23 of 90 (25.6 ± 4.6 %) patients included into group of interest. In more than half of cases Ab to several infectious agents were detected simultaneously. ITS of various specificity, in particular, to measles and rubella viruses, and VZV, known as MRZ-reaction, is characteristic of some autoimmune lesions of CNS, multiple sclerosis first of all. In fact, further research of 5 patients with MRZ-reaction confirmed their autoimmune failure of CNS. Detection of ITS in the CSF samples didn’t depend on concentration of specific Ab in serum and CSF and wasn’t followed by HEB dysfunctions which were observed with the same frequency in patients with or without ITS (13.0 % and 13.6 % respectively). Conclusion: Specific Ab synthesis to several neurotropic pathogens in the CSF of significant part of examined patients was established. Thus, diagnostic value of ITS of specific immunoglobulins seems to be limited to cases in which autoimmune damage of the CNS is suspected.


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