Rapid diagnosis in serology. / Diagnóstico rápido en serología.

Serological diagnosis of acute phase infections implies the detection of IgM specific response, an effective marker of primary infection, but with less clinical significance in reactivations or reinfections. The aim of this article is to provide an updated view of the rapid diagnosis in serology by detecting the IgM isotype and reviewing its applications and limitations. Point-of-care (PoC) tests are analyzed. PoC tests are used in geographical areas where traditional tests are not available, as well as in other circumstances where their use brings the diagnosis directly to the target population. Likewise, their use reduces the response time between taking the sample and the diagnosis, making it easier to make clinical decisions. PoC assays have proven cost-effective, especially in preventing vertical transmission of syphilis and HIV infection.

[Serological diagnosis of congenital infections and algorithms to improve diagnostic efficacy]. / Diagnóstico serológico de las infecciones congénitas y algoritmos para mejorar la eficacia diagnóstica.

Congenital infection is those transmitted by the mother to the fetus before delivery. It can occur transplacentally or by direct contact with the pathogen during birth or in the immediate postnatal period. Congenital infection can be due to viruses (rubella, cytomegalovirus, herpes simplex, varicella-zoster, hepatitis B and C virus, human inunodeficiencia, erythrovirus B19) as bacteria (Treponema pallidum) and parasites (Toxoplasma gondii and Trypanosoma cruzi). Serological diagnosis of congenital infection is based on both the knowledge of infectious serology in the mother, including the systematic serological screening and diagnostic aspects of the determination of IgM and confirmatory methods, IgG avidity tests, establishment of antibody profiles, and in the diagnosis the neonate. Serological diagnosis of congenital infection in the newborn is mainly based on the detection of specific IgM usually by immunoenzymatic assays or immunochemiluminescence techniques. In some instances it is important to perform the serological follow up of the newborn to confirm the congenital infection.

Comparison of imported Plasmodium ovale curtisi and P. ovale wallikeri infections among patients in Spain, 2005-2011.

Sequencing data from Plasmodium ovale genotypes co-circulating in multiple countries support the hypothesis that P. ovale curtisi and P. ovale wallikeri are 2 separate species. We conducted a multicenter, retrospective, comparative study in Spain of 21 patients who had imported P. ovale curtisi infections and 14 who had imported P. ovale wallikeri infections confirmed by PCR and gene sequencing during June 2005-December 2011. The only significant finding was more severe thrombocytopenia among patients with P. ovale wallikeri infection than among those with P. ovale curtisi infection (p = 0.031). However, we also found nonsignificant trends showing that patients with P. ovale wallikeri infection had shorter time from arrival in Spain to onset of symptoms, lower level of albumin, higher median maximum core temperature, and more markers of hemolysis than did those with P. ovale curtisi infection. Larger, prospective studies are needed to confirm these findings.

Molecular surveillance of HIV-1 in Madrid, Spain: a phylogeographic analysis.

The molecular epidemiology of HIV-1 is constantly changing, mainly as a result of human migratory flows and the high adaptive ability of the virus. In recent years, Spain has become one of Europe's main destinations for immigrants and one of the western European countries with the highest rates of HIV-positive patients. Using a phylogeographic approach, we have analyzed the relationship between HIV-1 variants detected in immigrant and native populations of the urban area of Madrid. Our project was based on two coincidental facts. First, resistance tests were extended to naïve and newly diagnosed patients, and second, the Spanish government legislated the provision of legal status to many immigrants. This allowed us to obtain a large data set (n = 2,792) from 11 Madrid hospitals of viral pol sequences from the two populations, and with this unique material, we explored the impact of immigration in the epidemiological trends of HIV-1 variants circulating in the largest Spanish city. The prevalence of infections by non-B HIV-1 variants in the studied cohort was 9%, rising to 25% among native Spanish patients. Multiple transmission events involving different lineages and subsubtypes were observed in all the subtypes and recombinant forms studied. Our results also revealed strong social clustering among the most recent immigrant groups, such as Russians and Romanians, but not in those groups who have lived in Madrid for many years. Additionally, we document for the first time the presence of CRF47_BF and CRF38_BF in Europe, and a new BG recombinant form found in Spaniards and Africans is tentatively proposed. These results suggest that the HIV-1 epidemic will evolve toward a more complex epidemiological landscape.

[Performance of the VIDAS automated immunoassay for the determination of Epstein-Barr virus serological status]. / Evaluación del sistema VIDAS para estudio de marcadores serológicos de infección por el virus Epstein Barr.

Enzyme linked fluorescent assays (VIDAS EBV VCA IgM, VIDAS EBV VCA/EA IgG and VIDAS EBV EBNA IgG (Biomérieux, France) were evaluated to determine markers for infection of Epstein Barr virus, as well as to establish antibody profiles, compared with immunofluorescence assays as reference. The assays evaluated showed good values for sensitivity, specificity and agreement, making them useful for their application in clinical laboratories.

Evaluation of the Chagas VirClia® and Chagas TESA VirClia® for the Diagnosis of Trypanosoma cruzi Infection.

Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is an important problem of public health even in regions where it is not endemic. Spain ranks second worldwide in terms of imported cases of T. cruzi infection in the chronic phase. The diagnosis in this stage is made via the detection of antibodies against T. cruzi. Therefore, we aimed to evaluate the sensitivity and specificity of two fully automated chemiluminescence immunoassays, Chagas VirClia® (CHR), which uses a mixture of recombinant antigens, and Chagas TESA VirClia® (TESA), the first chemiluminescence assay based on excretion-secretion antigens of trypomastigotes, both designed in monotest format. A retrospective case-control study was performed using 105 well-characterized samples: 49 from patients with CD, 22 from uninfected individuals, and 32 from patients with other pathologies. Sensitivity was 98% for CHR and 92% for TESA. In contrast, the specificity in both was 100%. Cross-reactivity was observed in leishmaniasis (2/10). CHR meets the criteria to become a tool for serological screening, while TESA has the potential for confirmation and cross-reaction discrimination. The monotest format allows its application in laboratories with a small number of samples. The high specificity of both assays is useful in areas where leishmaniasis is endemic.

A Prospective Study of the Serological, Clinical, and Epidemiological Features of a SARS-CoV-2 Positive Pediatric Cohort.

Background: SARS-CoV-2 was a global pandemic. Children develop a mild disease and may have a different rate of seroconversion compared to adults. The objective was to determine the number of seronegative patients in a pediatric cohort. We also reviewed the clinical−epidemiological features associated with seroconversion. Methods: A multicenter prospective observational study during September−November 2020, of COVID-19, confirmed by reverse transcription-polymerase chain reaction. Data were obtained 4−8 weeks after diagnosis. Blood samples were collected to investigate the humoral response, using three different serological methods. Results: A total of 111 patients were included (98 symptomatic), 8 were admitted to hospital, none required an Intensive Care Unit visit. Median age: 88 months (IQR: 24−149). Median time between diagnosis and serological test: 37 days (IQR: 34−44). A total of 19 patients were non-seroconverters when using three serological techniques (17.1%; 95% CI: 10.6−25.4); most were aged 2−10 years (35%, p < 0.05). Univariate analysis yielded a lower rate of seroconversion when COVID-19 confirmation was not present amongst household contacts (51.7%; p < 0.05). Conclusions: There was a high proportion of non-seroconverters. This is more commonly encountered in childhood than in adults. Most seronegative patients were in the group aged 2−10 years, and when COVID-19 was not documented in household contacts. Most developed a mild disease. Frequently, children were not the index case within the family.

[Evaluation of an Xpert EV (Cepheid®) molecular diagnostic technique for enteroviral meningitis]. / Evaluación de una técnica de diagnóstico molecular Xpert EV (Cepheid®) en la meningitis por enterovirus.

INTRODUCTION: Polymerase chain reaction (PCR) assays have shown to be useful and quick for the diagnosis of enterovirus in aseptic meningitis. The aim of our study was to analyse the changes in clinical practice after the introduction of a real-time polymerase chain reaction (RT-PCR) technique using the Xpert EV (Cepheid®) assay for the qualitative detection of enterovirus RNA in cerebrospinal fluid specimens from children with suspected viral meningitis. METHODS: A retrospective study was performed in children older than 1year, diagnosed with enterovirus meningitis in a third level hospital from November 2006 to February 2013. The first period, before the availability of Xpert EV (Cepheid®) (Group1, November 2006-August 2010) was compared with the later period (Group2, September 2010-February 2013). Clinical characteristics, the mean length of stay, and the cost per inpatient cases, were compared between the 2periods. RESULTS: Forty-one patients (60.9% male) were included, with a median age of 64 months (interquartile range 28-96). Twenty-six patients (63.4%) were included in Group2. There were non-statistically significant differences in the epidemiological, disease severity, and laboratory characteristics between both periods of study. A significant difference was observed in the mean length of stay, with it being shorter in Group2 (48hours vs 40.5hours, P=.039), and a significant lower inpatient cost per case (€779.77 vs €656.05, P<.05). CONCLUSION: Xpert EV (Cepheid®) assay was useful for decreasing the length of hospital stay and the costs associated with hospitalisation in children with enterovirus meningitis.

Diagnóstico rápido en serología / Rapid diagnosis in serology

El diagnóstico serológico de las infecciones en fase aguda implica la detección de la respuesta IgM específica, marcador eficaz de infección primaria, aunque con menos validez en las reactivaciones o reinfecciones. El objetivo de este artículo es proporcionar una visión actualizada del diagnóstico rápido en serología mediante la detección del isotipo IgM y revisar sus aplicaciones y limitaciones. Se analizan especialmente ensayos Point-of-Care (PoC) utilizados en áreas geográficas donde las pruebas tradicionales son inaccesibles, y en otras circunstancias donde su empleo acerca el diagnóstico a la población diana, debido a que pueden efectuarse en centros no sanitarios. Asimismo, su empleo disminuye el tiempo transcurrido entre la toma de muestra y el diagnóstico, facilitando al clínico la toma de decisiones. Los ensayos PoC han probado su coste-efectividad, especialmente en la prevención de la transmisión vertical de la sífilis y en la infección por el VIH

Serological diagnosis of acute phase infections implies the detection of IgM specific response, an effective marker of primary infection, but with less clinical significance in reactivations or reinfections. The aim of this article is to provide an updated view of the rapid diagnosis in serology by detecting the IgM isotype and reviewing its applications and limitations. Point-of-care (PoC) tests are analyzed. PoC tests are used in geographical areas where traditional tests are not available, as well as in other circumstances where their use brings the diagnosis directly to the target population. Likewise, their use reduces the response time between taking the sample and the diagnosis, making it easier to make clinical decisions. PoC assays have proven cost-effective, especially in preventing vertical transmission of syphilis and HIV infection

Evaluación de una técnica de diagnóstico molecular Xpert EV (Cepheid(R)) en la meningitis por enterovirus / Evaluation of an Xpert EV (Cepheid(R)) molecular diagnostic technique for enteroviral meningitis

Introducción: Las técnicas de biología molecular han demostrado ser útiles en la detección del enterovirus en niños con meningitis aséptica. El objetivo de nuestro estudio fue analizar cambios en la práctica clínica tras la introducción de una técnica de RT-PCR a tiempo real, ensayo Xpert EV (Cepheid(R)), para la detección de enterovirus en muestras de líquido cefalorraquídeo de niños con sospecha de meningitis vírica. Métodos: Estudio retrospectivo de los niños mayores de 1año diagnosticados de meningitis por enterovirus en un hospital de tercer nivel desde noviembre de 2006 a febrero de 2013. Se comparó el periodo previo a la introducción del ensayo Xpert EV (Cepheid(R)) (grupo1: noviembre 2006-agosto de 2010) con el periodo posterior (grupo2: septiembre 2010-febrero 2013). Se compararon las características clínicas, los tiempos de estancia media y los costes por hospitalización. Resultados: Se incluyeron 41 pacientes con una mediana de edad de 64 meses (rango intercuartílico, 28-96). En el grupo 2 se incluyeron 26 pacientes (63,4%). No hubo diferencias epidemiológicas, de gravedad, ni de laboratorio estadísticamente significativas entre los pacientes valorados en ambos grupos. Se observó una disminución significativa en la duración de estancia media hospitalaria en el grupo 2 (48 h vs 40,5 h, p = 0,039) y una disminución significativa en el gasto por paciente hospitalizado (779,77 Euros vs. 656,05 Euros, p<0,05). Conclusiones: La incorporación de la técnica Xpert EV (Cepheid(R)) permitió disminuir la estancia y el gasto asociado a hospitalización en niños con meningitis por enterovirus (AU)

Introduction: Polymerase chain reaction (PCR) assays have shown to be useful and quick for the diagnosis of enterovirus in aseptic meningitis. The aim of our study was to analyse the changes in clinical practice after the introduction of a real-time polymerase chain reaction (RT-PCR) technique using the Xpert EV (Cepheid(R)) assay for the qualitative detection of enterovirus RNA in cerebrospinal fluid specimens from children with suspected viral meningitis. Methods: A retrospective study was performed in children older than 1 year, diagnosed with enterovirus meningitis in a third level hospital from November 2006 to February 2013. The first period, before the availability of Xpert EV (Cepheid(R)) (Group 1, November 2006-August 2010) was compared with the later period (Group 2, September 2010-February 2013). Clinical characteristics, the mean length of stay, and the cost per inpatient cases, were compared between the 2 periods. Results: Forty-one patients (60.9% male) were included, with a median age of 64 months (interquartile range 28-96). Twenty-six patients (63.4%) were included in Group 2. There were non-statistically significant differences in the epidemiological, disease severity, and laboratory characteristics between both periods of study. A significant difference was observed in the mean length of stay, with it being shorter in Group2 (48 hours vs 40.5 hours, P = .039), and a significant lower inpatient cost per case (Euros 779.77 vs Euros 656.05, P < .05). Conclusion: Xpert EV (Cepheid(R)) assay was useful for decreasing the length of hospital stay and the costs associated with hospitalisation in children with enterovirus meningitis (AU)

Evaluation of four commercial systems for the diagnosis of Epstein-Barr virus primary infections.

To compare the performance of four diagnostic commercial systems for Epstein-Barr virus (EBV) serology (for IgM and IgG virus capsid antigen [VCA] and EBV nuclear antigen [EBNA] antibodies), a collection of 125 samples from clinically suspected infectious mononucleosis cases was studied. Indirect immunofluorescence (IIF) for VCA IgM and IgG antibodies and anticomplement immunofluorescence for EBNA antibodies (Meridian Bioscience Inc.) were used as reference methods. By these methods, the cases were classified EBV primary infection (presence of IgM to VCA or IgG to VCA in the absence of EBNA antibodies; n = 82), EBV past infection (presence of VCA IgG and EBNA antibodies in the absence of VCA IgM; n = 26), or no infection (negative for the three markers; n = 17). The following systems were tested: two chemiluminescent immunoassays (CLIAs; the Liason [CLIA-L; DiaSorin] and the Immulite 2000 [CLIA-I; Siemens]), immunofiltration (IF; All.Diag), and an enzyme-linked immunosorbent assay (ELISA; DiaSorin). In the IgM assays, sensitivities ranged from 67.1% (ELISA) to 92.2% (CLIA-L) and specificities ranged from 93.8% (CLIA-L) to 100% (IF). In the VCA IgG assays, sensitivities varied from 79.4% (IF) to 94.4% (CLIA-I) and specificities varied from 94.4% (IF and CLIA-L) to 100% (CLIA-I and ELISA). In EBNA assays, sensitivities ranged from 78.1% (IF) to 93.8% (CLIA-I) and specificities ranged from 32.3% (CLIA-L) to 91.4% (IF). In relation to EBV profiles, the corresponding figures for sensitivity (in detecting primary infection) for IF, CLIA-L, CLIA-I, and ELISA were 92.7%, 93.8%, 89%, and 89.6%, respectively, and those for specificity (to exclude primary recent infection) were 90.7%, 94.6%, 97.7%, and 95.2%, respectively. Although there were limitations in some individual markers, especially CLIA-L for EBNA IgG, the systems evaluated appear to be useful for diagnosis of EBV infection.

Diagnóstico serológico de las infecciones congénitas y algoritmos para mejorar la eficacia diagnóstica / Serological diagnosis of congenital infections and algorithms to improve diagnostic efficacy

Puede ocurrir por vía transplacentaria o por contacto directo con el patógeno durante el parto o en el período posnatal. Se puede producir infección congénita tanto por virus (rubéola, citomegalovirus, herpes simple, varicela-zóster, hepatitis B y C, virus de la inmunodeficiencia humana, erythrovirus B19) como por bacterias (Treponema pallidum) y parásitos (Toxoplasma gondii y Trypanosoma cruzi). El diagnóstico serológico de la infección congénita se basa tanto en el conocimiento de la serología infecciosa en la madre, incluyendo el control serológico sistemático y aspectos del diagnóstico por determinación de IgM y métodos confirmatorios, como los ensayos de avidez de IgG o el establecimiento de perfiles de anticuerpos, como en el diagnóstico en el neonato. El diagnóstico serológico de la infección congénita en el recién nacido se basa fundamentalmente en la detección de IgM específica, generalmente mediante técnicas inmunoenzimáticas o de inmunoquimioluminiscencia; en ocasiones es de importancia realizar el seguimiento serológico del recién nacido para confirmar la infección congénita

Congenital infection is those transmitted by the mother to the fetus before delivery. It can occur transplacentally or by direct contact with the pathogen during birth or in the immediate postnatal period. Congenital infection can be due to viruses (rubella, cytomegalovirus, herpes simplex, varicella-zoster, hepatitis B and C virus, human inunodeficiencia, erythrovirus B19) as bacteria (Treponema pallidum) and parasites (Toxoplasma gondii and Trypanosoma cruzi). Serological diagnosis of congenital infection is based on both the knowledge of infectious serology in the mother, including the systematic serological screening and diagnostic aspects of the determination of IgM and confirmatory methods, IgG avidity tests, establishment of antibody profiles, and in the diagnosis the neonate. Serological diagnosis of congenital infection in the newborn is mainly based on the detection of specific IgM usually by immunoenzymatic assays or immunochemiluminescence techniques. In some instances it is important to perform the serological follow up of the newborn to confirm the congenital infection

Comparison of IgG avidity assays in the confirmation of the diagnosis of cytomegalovirus primary infection.

We have compared three ELISA techniques and one chemiluminescence immunoassay technique for determining cytomegalovirus (CMV) immunoglobulin G (IgG) avidity in serum samples from patients with recent and past CMV infections. Sensitivity varied from 84.6% to 100%; and specificity from 78.6% to 100%. IgG avidity assays appear to be adequate additional tools for characterizing CMV infections.

Evaluación del sistema VIDAS para estudio de marcadores serológicos de infección por el virus Epstein Barr / Performance of the VIDAS automated immunoassay for the determination of Epstein-Barr virus serological status

Se han evaluado ensayos de fluorescencia ligada a enzima (VIDAS EBV VCA IgM, VIDAS EBV VCA/EA IgG y VIDAS EBV EBNA IgG (Biomérieux, Francia) para la determinación de marcadores de infección por el virus Epstein Barr, así como para el establecimiento de perfiles de anticuerpos, comparándolos con ensayos de inmunofluorescencia como referencia. Los ensayos evaluados han mostrado buenas características de sensibilidad, especificidad y coincidencia porcentual de resultados, lo que les hace adecuados para su aplicación en laboratorios de diagnóstico clínico (AU)

Enzyme linked fluorescent assays (VIDAS EBV VCA IgM, VIDAS EBV VCA/EA IgG and VIDAS EBV EBNA IgG (Biomérieux, France) were evaluated to determine markers for infection of Epstein Barr virus, as well as to establish antibody profiles, compared with immunofluorescence assays as reference. The assays evaluated showed good values for sensitivity, specificity and agreement, making them useful for their application in clinical laboratories (AU)

Las relaciones con otras especialidades: la visión de los microbiólogos / Relationships with other specialties: the view of microbiologists

La microbiología es una ciencia interpretativa y, como tal, necesita interlocutores cualificados, y esta función es una de las principales actividades del microbiólogo. El presente artículo pretende analizar lo que significa ser microbiólogo a comienzos del siglo XXI, presentar nuestros objetivos y comentar las relaciones profesionales mantenidas con otras especialidades. Las nuevas tecnologías y la automatización han cambiado sustancialmente las características de los laboratorios de microbiología y han modificado la forma en la que el microbiólogo desarrolla su actividad profesional. En la actualidad, la organización del laboratorio de microbiología clínica del futuro es objeto de controversia y la forma en que ésta se enfoque y desarrolle influirá, inevitablemente, en todos los especialistas que nos dedicamos al estudio de la infección. Los especialistas en microbiología deben realizar la función asistencial, docente e investigadora de forma coordinada con el resto de las especialidades implicadas en el diagnóstico, tratamiento, prevención y control de las infecciones. Para que la colaboración entre los profesionales de las distintas especialidades sea productiva y lo menos conflictiva posible, la relación se ha de basar en el respeto, complementariedad, cooperación y transparencia. Sólo así podremos conseguir que nuestro trabajo contribuya a proporcionar a los pacientes la mejor atención sanitaria posible y daremos contenido al futuro de nuestra especialidad

Clinical microbiology is an interpretative science and, as such, requires qualified professionals, interpretation being one of the most important activities performed by microbiologists. This article aims to analyze what it means to be a clinical microbiologist at the beginning of the 21st century, to present our professional objectives, and to discuss the professional relationship between microbiology and other specialties. Technological improvements and automation have substantially changed the characteristics of modern microbiology laboratories and have modified microbiologists' professional activity. Currently, the organization of the clinical microbiology laboratory in the near future is controversial, and strategies and decisions that must be urgently adopted will inevitably influence not only microbiologists' professional activity but also that of other specialists dealing with infectious diseases. Clinical microbiology specialists must develop the three classical professional functions: healthcare, teaching and research. These tasks should be carried out in a coordinated and cooperative fashion with other specialists interested in the diagnosis, treatment, prevention, and control of infectious diseases. To make this collaboration as productive and conflict-free as possible, the relationship must be based on complementarily, cooperation, and transparency. Only in this way will the work of microbiologists contribute to optimal patient care and provide a rationale for the future of our profession

Anomalías y patrones serológicos infrecuentes de los marcadores diagnósticos del virus de la hepatitis B / Abnormalities and infrequent serological patterns of diagnostic markers of hepatitis B virus

El virus de la hepatitis B (VHB) representa un problema de salud pública mundial, a pesar de su mejor conocimiento y de los avances producidos en el diagnóstico, el tratamiento y la prevención. Los marcadores serológicos del VHB constituyen una parte importante de las determinaciones realizadas en el Servicio de Microbiología, debido a su utilidad para efectuar el diagnóstico, conocer la evolución, establecer el pronóstico y realizar los estudios epidemiológicos. En algunas ocasiones, los resultados obtenidos en las pruebas serológicas son difíciles de interpretar. En estas situaciones, las actitudes deben encaminarse a diferenciar las reactividades inespecíficas de las auténticas, verificando la especificidad de los ensayos o comprobando la sensibilidad de la prueba utilizada, repitiendo el ensayo por técnicas o métodos diferentes. En ocasiones, será necesario obtener otra muestra lo antes posible, para analizarla junto con la que presenta el problema o plantearse un seguimiento microbiológico y clínico del paciente. Finalmente, la interpretación de los resultados obtenidos siempre deberá efectuarse junto con la historia clínica del paciente. El objetivo de esta revisión es comentar algunos de los perfiles serológicos infrecuentes o “anómalos” y su posible interpretación según el contexto clínico

Despite advances in the diagnosis, treatment and prevention of hepatitis B virus (HBV) infection, this disease remains a public health threat worldwide. Consequently, serological markers of HBV constitute a substantial proportion of the total workload performed in microbiology laboratories, because of their utility as tools for diagnosis, monitoring and prognosis and for epidemiological studies. Sometimes, serological test results are difficult to interpret. In these cases, nonspecific reactivities should be clearly differentiated from true test results to assess the specificity and/or the sensitivity of the assays, either by repeating the tests or by using different techniques or methods. In some instances, drawing a new blood sample as soon as possible can be required. The second sample should be analyzed in parallel with the first specimen to clarify a doubtful initial result or to plan the patient's microbiological and clinical follow-up. Finally, interpretation of the results obtained should always be performed together with evaluation of the patient's clinical history. The present review aims to discuss some infrequent or "anomalous" serological patterns and their possible interpretation according to the clinical context

La vacuna triple vírica: viejos virus, nuevos problemas / Triple vaccination: old viruses, new problems

No disponible

Amplicor HIV-1 Monitor y NucliSens HIV-1 QT: comparación de dos técnicas para la determinación de la carga vírica del virus de la inmunodeficiencia humana tipo 1 / Amplicor HIV-1 Monitor and Nuclisens HIV-1 QT: comparison of two new techniques to determine the viral load of HIV-1

No disponible