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2.
Int Arch Allergy Immunol ; 179(1): 62-73, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30904913

RESUMO

Recurrent severe bacterial and fungal infections are characteristic features of the rare genetic immunodeficiency disorder chronic granulomatous disease (CGD). The disease usually manifests within the first years of life with an incidence of 1 in approximately 200,000 live births. The incidence is higher in Iran and Morocco where it reaches 1.5 per 100,000 live births. Mutations have been described in the 5 subunits of NADPH oxidase, mostly in gp91phox and p47phox, with fewer mutations reported in p67phox, p22phox, and p40phox. These mutations cause loss of superoxide production in phagocytic cells. CYBB, the gene encoding the large gp91phox subunit of the transmembrane component cytochrome b558 of the NADPH oxidase complex, is localized on the X-chromosome. Genetic defects in CYBB are responsible for the disease in the majority of male CGD patients. CGD is associated with the development of granulomatous reactions in the skin, lungs, bones, and lymph nodes, and chronic infections may be seen in the liver, gastrointestinal tract, brain, and eyes. There is usually a history of repeated infections, including inflammation of the lymph glands, skin infections, and pneumonia. There may also be a persistent runny nose, inflammation of the skin, and inflammation of the mucous membranes of the mouth. Gastrointestinal problems can also occur, including diarrhea, abdominal pain, and perianal abscesses. Infection of the bones, brain abscesses, obstruction of the genitourinary tract and/or gastrointestinal tract due to the formation of granulomatous tissue, and delayed growth are also symptomatic of CGD. The prevention of infectious complications in patients with CGD involves targeted prophylaxis against opportunistic microorganisms such as Staphylococcus aureus, Klebsiella spp., Salmonella spp. and Aspergillus spp. In this review, we provide an update on organ involvement and the association with specific isolated microorganisms in CGD patients.


Assuntos
Infecções Bacterianas/etiologia , Doença Granulomatosa Crônica/complicações , Micoses/etiologia , Autoimunidade , Criança , Pré-Escolar , Feminino , Doença Granulomatosa Crônica/genética , Doença Granulomatosa Crônica/imunologia , Humanos , Lactente , Abscesso Hepático/etiologia , Pneumopatias/etiologia , Masculino , NADPH Oxidases/genética , Dermatopatias/etiologia
3.
J Pediatric Infect Dis Soc ; 7(suppl_2): S72-S74, 2018 Dec 26.
Artigo em Inglês | MEDLINE | ID: mdl-30590625

RESUMO

Cytomegalovirus (CMV) remains a significant contributor to morbidity and death after pediatric solid and stem cell transplantation. Decisions regarding prevention and treatment often lack pediatric-specific data to drive decision making. We present here a case-based discussion around some of these specific topics and focus on approaches to CMV prevention, post-CMV secondary prophylaxis options, and identification and treatment of resistant CMV infection, including emerging antiviral agents and the use of cytotoxic CMV-specific T-cells, in the setting of pediatric hematopoietic stem cell transplantation.


Assuntos
Infecções por Citomegalovirus/prevenção & controle , Doença Granulomatosa Crônica/terapia , Transplante de Células-Tronco Hematopoéticas , Antivirais/uso terapêutico , Criança , Citomegalovirus/imunologia , Infecções por Citomegalovirus/complicações , Infecções por Citomegalovirus/virologia , Farmacorresistência Viral , Evolução Fatal , Foscarnet/uso terapêutico , Doença Granulomatosa Crônica/complicações , Humanos , Masculino , Recidiva , Insuficiência Respiratória/etiologia , Medição de Risco , Prevenção Secundária , Linfócitos T Citotóxicos , Valganciclovir/uso terapêutico , Carga Viral
5.
J Pediatric Infect Dis Soc ; 7(suppl_1): S6-S11, 2018 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-29746674

RESUMO

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency that is caused by defects in the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. The disease presents in most patients initially with infection, especially of the lymph nodes, lung, liver, bone, and skin. Patients with CGD are susceptible to a narrow spectrum of pathogens, and Staphylococcus aureus, Burkholderia cepacia complex, Serratia marcescens, Nocardia species, and Aspergillus species are the most common organisms implicated in North America. Granuloma formation, most frequently in the gastrointestinal and genitourinary systems, is a common complication of CGD and can be seen even before diagnosis. An increased incidence of autoimmune disease has also been described in patients with CGD and X-linked female carriers. In patients who present with signs and symptoms consistent with CGD, a flow cytometric dihydrorhodamine neutrophil respiratory burst assay is a quick and cost-effective way to evaluate NADPH oxidase function. The purpose of this review is to highlight considerations for and challenges in the diagnosis of CGD.


Assuntos
Doença Granulomatosa Crônica/diagnóstico , Diagnóstico Diferencial , Feminino , Granuloma/etiologia , Doença Granulomatosa Crônica/complicações , Humanos , Masculino , Mutação , Micoses/etiologia , NADPH Oxidases/genética , NADPH Oxidases/fisiologia , Nitroazul de Tetrazólio
6.
J Pediatric Infect Dis Soc ; 7(suppl_1): S18-S24, 2018 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-29746679

RESUMO

Chronic granulomatous disease (CGD), a primary immunodeficiency characterized by a deficient neutrophil oxidative burst and the inadequate killing of microbes, is well known to cause a significantly increased risk of invasive infection. However, infectious complications are not the sole manifestations of CGD; substantial additional morbidity is driven by noninfectious complications also. These complications can include, for example, a wide range of inflammatory diseases that affect the gastrointestinal tract, lung, skin, and genitourinary tract and overt autoimmune disease. These diseases can occur at any age and are especially problematic in adolescents and adults with CGD. Many of these noninfectious complications present a highly challenging therapeutic conundrum, wherein immunosuppression must be balanced against an already markedly increased risk of invasive fungal and bacterial infections. In this review, the myriad noninfectious complications of CGD are discussed, as are important gaps in our understanding of these processes, which warrant further investigation.


Assuntos
Granuloma/etiologia , Doença Granulomatosa Crônica/complicações , Doenças Inflamatórias Intestinais/etiologia , Pneumopatias/etiologia , Doenças Autoimunes/complicações , Diagnóstico Diferencial , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Pneumopatias/diagnóstico
7.
J Pediatric Infect Dis Soc ; 7(suppl_1): S25-S30, 2018 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-29746681

RESUMO

Chronic granulomatous disease (CGD) is a primary immunodeficiency that confers a markedly increased risk of bacterial and fungal infections caused by certain opportunistic pathogens. Current evidence supports the use of prophylactic antibacterial, antifungal, and immunomodulatory therapies designed to prevent serious or life-threatening infections in patients with CGD. In this review, we discuss current strategies for the prevention of infections in children and adults with CGD and the evidence that supports those strategies. In addition, we address current challenges and opportunities for future research in this important area.


Assuntos
Antibioticoprofilaxia , Antifúngicos/uso terapêutico , Infecções Bacterianas/prevenção & controle , Doença Granulomatosa Crônica/complicações , Interferon gama/uso terapêutico , Micoses/prevenção & controle , Antibacterianos/uso terapêutico , Infecções Bacterianas/etiologia , Humanos , Micoses/etiologia
8.
Arch. Soc. Esp. Oftalmol ; 93(4): 206-208, abr. 2018. ilus
Artigo em Espanhol | IBECS | ID: ibc-173120

RESUMO

Objetivo/método: Generalmente la primera manifestación de la sarcoidosis es a nivel pulmonar, por lo que se presenta el caso de una mujer de 40 años de edad, quien presenta como primera expresión de la enfermedad aumento de volumen de la glándula lagrimal y ptosis mecánica del párpado superior izquierdo. Resultado/conclusión: Después de realizar diversos estudios inmunológicos con resultados negativos, estudios de imagen, toma de biopsia glandular y de ganglios localizados en mediastino se concluye en el diagnóstico de sarcoidosis sistémica con presentación primaria de la glándula lagrimal y se inicia tratamiento con metotrexate vía oral con respuesta favorable


Objective/method: The first manifestation of sarcoidosis is usually at the pulmonary level. The case is described of a 40-year-old female patient, who presented with an increased volume of the lacrimal gland and mechanical ptosis of upper left eyelid as the first expression of this disease. Result/conclusion: The diagnosis of systemic sarcoidosis with primary presentation of the lacrimal gland was made after performing several immunological studies with negative results, imaging studies, and taking of glandular and lymph node biopsies. A favourable response was achieved with oral methotrexate treatment


Assuntos
Humanos , Feminino , Adulto , Sarcoidose/diagnóstico por imagem , Aparelho Lacrimal/diagnóstico por imagem , Biópsia , Órbita/diagnóstico por imagem , Aparelho Lacrimal/patologia , Doença Granulomatosa Crônica/complicações , Acuidade Visual , Radiografia Torácica/métodos
10.
Arch. Soc. Esp. Oftalmol ; 93(2): 101-104, feb. 2018. ilus
Artigo em Espanhol | IBECS | ID: ibc-172587

RESUMO

Introducción: La tuberculosis (TB) es una infección granulomatosa crónica, y la granulomatosis con poliangeítis (GP) es una vasculitis de vaso pequeño, ambas pudiendo comprometer los pulmones. La asociación de estas es rara. Ambas tienen características similares, lo que dificulta el diagnóstico diferencial. Caso clínico: Mujer de 37 años, en tratamiento para TB pulmonar, que presentó proptosis ocular izquierda, edema y eritema de párpado y conjuntiva. La biopsia orbitaria reveló GP. Los anticuerpos anticitoplasma de neutrófilos se encontraban elevados. Se inició tratamiento inmunosupresor, con buena respuesta. Conclusión: La TB y la GP pueden asociarse. El diagnóstico debe incluir anticuerpos anticitoplasma de neutrófilos y también biopsia, para seleccionar el tratamiento preciso (AU)


Introduction: Tuberculosis (TB) is a chronic granulomatose infection, and granulomatosis with polyangiitis (GP) is a small vessel vasculitis, both of which affect the lungs. The combination of these diseases is rare. Both have similar clinical features, making the differential diagnosis difficult. Case report: It concerns a 37 year-old female undergoing treatment for pulmonary TB, who presented with left ocular proptosis, eyelid and conjunctival edema and erythema. Orbital biopsy revealed GP. C-Anti-neutrophil cytoplasmic antibodies were elevated. The patient responded well to immunosuppressive treatment. Conclusion: TB and GP can associate. Diagnosis should include not only C-anti-neutrophil cytoplasmic antibodies, but also a biopsy, in order to select the appropriate treatment (AU)


Assuntos
Humanos , Feminino , Adulto , Granulomatose com Poliangiite/diagnóstico por imagem , Granulomatose com Poliangiite/tratamento farmacológico , Tuberculose/complicações , Tuberculose/diagnóstico por imagem , Imunossupressores/uso terapêutico , Doença Granulomatosa Crônica/complicações , Doença Granulomatosa Crônica/tratamento farmacológico , Diagnóstico Diferencial , Anticorpos Anticitoplasma de Neutrófilos/análise , Exoftalmia/diagnóstico por imagem , Exoftalmia/tratamento farmacológico , Acuidade Visual , Radiografia Torácica/métodos , Prednisona/uso terapêutico
12.
Arch Argent Pediatr ; 115(6): e458-e461, 2017 Dec 01.
Artigo em Espanhol | MEDLINE | ID: mdl-29087135

RESUMO

BACKGROUND: Arthrographis kalrae is a hyaline fungus that grows forming arthroconidia. It is an opportunistic pathogen that causes infections in immunocompromised as in immunocompetent people and has been rarely isolated from human clinical samples. CASE REPORT: We describe the case of a male child with primary immunodeficiency who initially presented unilateral pneumonia and progressed to bilateral involvement despite antibiotic, antifungal treatment. A. kalrae was diagnosed by pulmonary biopsy. He received posaconazole with resolution of disease. CONCLUSIONS: This is the first case of A. kalrae pulmonary infection in a pediatric patient with chronic granulomatous disease in Argentina.


Assuntos
Ascomicetos , Doença Granulomatosa Crônica/complicações , Pneumopatias Fúngicas/microbiologia , Micoses/complicações , Pré-Escolar , Humanos , Pneumopatias Fúngicas/tratamento farmacológico , Masculino , Micoses/tratamento farmacológico , Micoses/microbiologia
13.
Scand J Immunol ; 86(6): 486-490, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29063637

RESUMO

Chronic granulomatous disease (CGD) is an inherited immunodeficiency disorder affecting the microbicidal function of the phagocytes. It is characterized by susceptibility to recurrent infections leading to significant morbidity and mortality. Antibacterial and antifungal prophylaxis, though, has significantly reduced the rate and severity of the infections; the breakthrough infections still remain a challenge. Currently, allogenic haematopoietic stem cell transplantation is the only curative option which is very expensive and unavailable for many due to lack of suitable donor. Thus, prenatal diagnosis (PND) forms an important component of management in the affected families. PND is challenging in families approaching late in pregnancy with an uncharacterized molecular defect. In such cases, PND can be performed by analysis of NADPH activity of fetal blood (FB) neutrophils at 18-20 weeks of gestation. Cord blood samples at 18 weeks of gestation from healthy control were used to establish normal ranges for NBT and DHR. PND was offered for six pregnancies (NBT: n = 3, DHR: n = 6) with index cases of CGD confirmed by abnormal NBT and DHR analysis. NBT and DHR tests were found to be negative for all the six cases, confirming the same on samples post-delivery. NBT and DHR tests offer a rapid and sensitive PND of CGD in the absence of facilities for molecular diagnosis. It was observed that addition of CD15 along with CD45 led to an accurate DHR analysis. It is recommended to perform the diagnosis with adequate precautions only at centres with considerable experience and expertise in the diagnosis of CGD.


Assuntos
Doença Granulomatosa Crônica/diagnóstico , Imunofenotipagem/métodos , Neutrófilos/imunologia , Diagnóstico Pré-Natal/métodos , Antibioticoprofilaxia , Células Cultivadas , Feminino , Sangue Fetal/citologia , Citometria de Fluxo , Seguimentos , Doença Granulomatosa Crônica/complicações , Humanos , Lactente , Controle de Infecções , Masculino , NADP/metabolismo , Gravidez , Explosão Respiratória , Rodaminas
14.
Pediatr Allergy Immunol ; 28(8): 801-809, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28981976

RESUMO

BACKGROUND: Chronic granulomatous disease (CGD) is a primary immunodeficiency of phagocytes, characterized by life-threatening infections and hyperinflammation. Due to survival improvement, inflammatory bowel disease (IBD) is becoming increasingly relevant. Here, we report our 20 year experience. METHODS: We retrospectively analyzed clinic, endoscopic, and histologic features, as well as the management of CGD-IBD patients referred to the Bambino Gesù Children's Hospital in Rome, Italy. RESULTS: Of 20 patients with CGD, 9 presented with CGD-IBD at diagnosis and/or during follow-up. Symptoms occurred at a median age of 16 years (range 3.2-42), with a median delay of 6 months for endoscopic confirmation. Patients mainly complained of nonspecific diarrhea (55%), with discrepancy between symptom paucity and severe endoscopic appearance, mainly represented by extensive colonic involvement (44%). Histology revealed at least 2 characteristic features (epithelioid granulomas, pigmented macrophages, and increased eosinophils) in 78% of patients. Eight of 9 patients received oral mesalamine, and 5 required systemic steroids. One patient received azathioprine due to steroid dependence. No patient required biological therapy or surgery. Clinical remission was obtained in all patients, but the majority complained of mild relapses. Two episodes of severe infection occurred early after steroid therapy. CONCLUSIONS: Penetrance of CGD-IBD increases with age. Clinical manifestations may be subtle, and clinicians should have a low threshold to recommend endoscopy. Treatment with NSAIDs and/or steroids achieves a good response, but relapses usually occur. Infection surveillance is mandatory during treatment, to prevent opportunistic infections. A close collaboration between pediatric immunologists and gastroenterologists is pivotal, including combined follow-up.


Assuntos
Doença Granulomatosa Crônica/complicações , Doenças Inflamatórias Intestinais/etiologia , Adolescente , Adulto , Anti-Inflamatórios/uso terapêutico , Criança , Pré-Escolar , Feminino , Seguimentos , Doença Granulomatosa Crônica/diagnóstico , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Masculino , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
15.
Turk Kardiyol Dern Ars ; 45(7): 660-663, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28990950

RESUMO

A 3-year-old girl with the diagnosis of chronic granulomatous disease (CGD) was hospitalized for bronchopneumonia and congestive heart failure. Her medical history included methylprednisolone medication for autoimmune gastric outlet obstruction. Computed tomography revealed pneumonic infiltrations and pericardial thickening. A pulsed-wave Doppler recording revealed E/A >1. During a pericardiectomy, multiple islands of thick, firm-walled, fibrinous exudate-containing, small abscess formations were observed. Histopathological evaluation of pericardial tissue revealed granulomatous inflammation. Aspergillus fumigatus was cultured from the abscess. In conclusion, development of constrictive aspergillus pericarditis should be considered in patients with CGD because immediate initiation of antifungal management with aggressive surgical treatment is life-saving.


Assuntos
Aspergilose/etiologia , Aspergillus fumigatus/isolamento & purificação , Doença Granulomatosa Crônica/complicações , Pericardite Constritiva/etiologia , Antifúngicos/administração & dosagem , Antifúngicos/uso terapêutico , Aspergilose/tratamento farmacológico , Aspergilose/cirurgia , Broncopneumonia/diagnóstico por imagem , Broncopneumonia/tratamento farmacológico , Broncopneumonia/microbiologia , Broncopneumonia/cirurgia , Pré-Escolar , Ecocardiografia , Ecocardiografia Doppler de Pulso , Feminino , Doença Granulomatosa Crônica/tratamento farmacológico , Humanos , Interferon gama/administração & dosagem , Interferon gama/uso terapêutico , Pericardite Constritiva/diagnóstico por imagem , Pericardite Constritiva/tratamento farmacológico , Pericardite Constritiva/cirurgia , Pericárdio/patologia , Radiografia Torácica , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Tomografia Computadorizada por Raios X , Voriconazol/administração & dosagem , Voriconazol/uso terapêutico
16.
Infez Med ; 25(3): 270-273, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28956546

RESUMO

Aspergillus myofasciitis is a rare infection of the muscles and their fascial sheaths that has been reported in patients with immune deficiencies of various kinds but, until now, not with chronic granulomatous disease (CGD). Patients affected by CGD are at high risk of invasive aspergillus infections. The case described involves a 14-year-old boy with a severe autosomal recessive CGD who was admitted to hospital with an Aspergillus myofasciitis of the left forearm. He was treated with liposomal amphotericin for 14 days and then with oral voriconazole for three months with an excellent clinical outcome. He did not evidence any recurrence in the following 30 months using itraconazole prophylaxis.


Assuntos
Aspergilose/etiologia , Aspergillus fumigatus/isolamento & purificação , Fasciite/etiologia , Doença Granulomatosa Crônica/complicações , Piomiosite/etiologia , Adolescente , Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Aspergilose/tratamento farmacológico , Aspergilose/microbiologia , Aspergilose/cirurgia , Terapia Combinada , Desbridamento , Quimioterapia Combinada , Fasciite/tratamento farmacológico , Fasciite/microbiologia , Fasciite/cirurgia , Antebraço , Humanos , Interferon gama/uso terapêutico , Itraconazol/uso terapêutico , Masculino , Piomiosite/tratamento farmacológico , Piomiosite/microbiologia , Piomiosite/cirurgia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
18.
Medicine (Baltimore) ; 96(31): e7718, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28767612

RESUMO

RATIONALE: The simultaneous occurrence of pyoderma gangrenosum (PG) and chronic granulomatous disease (CGD) is uncommon and few cases have been reported worldwide. PATIENT CONCERNS: PG is a rare, chronic, ulcerative, neutrophilic skin disease of unknown etiology that requires immunosuppressive treatment. CGD belongs to Primary Immune Deficiencies in which the main defect lies in an inability of the phagocytic cells to generate superoxide making patients susceptible to serious, potentially life-threatening bacterial and fungal infections. DIAGNOSES: In this manuscript, we present a case of ulcerative pyoderma gangrenosum in a 28-year-old man with recent diagnosis of chronic granulomatous disease during hospitalization for resistant pulmonary tuberculosis complicated with Aspergillus infection. INTERVENTIONS: Second-line therapy with dapsone and intravenous immunoglobulin was initially administered but eventually corticosteroids were added to treatment because of disease progression and further ulceration. OUTCOMES: Patient's ulcers were gradually healed with no side effects. LESSONS: Corticosteroids could be used under close monitoring for the treatment of PG in a patient with CGD, despite the increased risk for infections.


Assuntos
Doença Granulomatosa Crônica/complicações , Pioderma Gangrenoso/complicações , Úlcera/complicações , Adulto , Diagnóstico Diferencial , Doença Granulomatosa Crônica/diagnóstico , Doença Granulomatosa Crônica/patologia , Doença Granulomatosa Crônica/terapia , Humanos , Masculino , Pioderma Gangrenoso/diagnóstico , Pioderma Gangrenoso/patologia , Pioderma Gangrenoso/terapia , Úlcera/diagnóstico , Úlcera/patologia , Úlcera/terapia
19.
Tuberk Toraks ; 65(1): 56-59, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28621249

RESUMO

Chronic granulomatous disease (CGD) is a genetically heterogeneous primary immunodeficiency that is characterized by recurrent and life-threatening infections resulting from defects in phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and granuloma formation due to increased inflammatory response. The most commonly involved organs are the lungs, skin, lymph nodes, and liver due to infection. It may present with recurrent pneumonia, hilar lymphadenopathy, empyema, abscess, reticulonodular patterns, and granulomas due to lung involvement. In recent years, mycobacterial disease susceptibility has been reported in CGD cases. This article presents two male cases, one of whom is aged 18 months and the other is aged 5 years, who were diagnosed with CGD and tuberculosis during examination due to extended pneumonia. This report is presented because CGD should be considered not only in the presence of skin abscesses and Aspergillus infections, but also in the differential diagnosis for cases with BCG-itis and/or tuberculosis. It should be kept in mind that mycobacterial infections can occur during the course of the disease.


Assuntos
Doença Granulomatosa Crônica/complicações , Tuberculose/complicações , Pré-Escolar , Diagnóstico Diferencial , Suscetibilidade a Doenças , Granuloma/diagnóstico , Doença Granulomatosa Crônica/diagnóstico , Humanos , Lactente , Doenças Linfáticas/diagnóstico , Masculino , Pneumonia/diagnóstico , Tomografia Computadorizada por Raios X , Tuberculose/diagnóstico
20.
Pediatr Infect Dis J ; 36(12): 1165-1166, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28650935

RESUMO

Granulibacter bethesdensis is a Gram-negative bacillus described as a pathogen exclusively in patients with chronic granulomatous disease, a phagocytic disorder that impairs the ability to clear catalase-producing organisms. Granulibacter usually causes chronic and recurrent lymphadenopathies. We report the fatal case of a 4-year-old boy with chronic granulomatous disease, who presented with sepsis after a few days of abdominal pain and diarrhea.


Assuntos
Acetobacteraceae , Infecções por Bactérias Gram-Negativas , Doença Granulomatosa Crônica , Sepse , Pré-Escolar , Coagulação Intravascular Disseminada , Evolução Fatal , Doença Granulomatosa Crônica/complicações , Doença Granulomatosa Crônica/genética , Humanos , Masculino
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