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Pediatric Drugs

, Volume 7, Issue 3, pp 163–176 | Cite as

Tick-Borne Infections in Children

Epidemiology, Clinical Manifestations, and Optimal Management Strategies
  • Steven C. BuckinghamEmail author
Therapy In Practice

Abstract

Ticks can transmit bacterial, protozoal, and viral infections to humans. Specific therapy is available for several of these infections. Doxycycline is the antimicrobial treatment of choice for all patients, regardless of age, with Rocky Mountain spotted fever, human monocytic ehrlichiosis, or human granulocytic ehrlichiosis. Chloramphenicol has been used to treat these infections in children but is demonstrably inferior to doxycycline. In patients with Mediterranean spotted fever, doxycycline, chloramphenicol, and newer macrolides all appear to be effective therapies. Therapy of Lyme disease depends on the age of the child and stage of the disease. For early localized disease, amoxicillin (for those aged <8 years) or doxycycline (for those aged ≥8 years) is effective. Doxycycline, penicillin V (phenoxymethylpenicillin) or penicillin G (benzylpenicillin) preparations, and erythromycin are all effective treatments for tick-borne relapsing fever. Hospitalized patients with tularemia should receive gentamicin or streptomycin. Doxycycline and ciprofloxacin have each been investigated for the treatment of tularemia in outpatients; however, these agents do not yet have established roles in the treatment of this disease in children. Combination therapy with clindamycin and quinine is preferred for children with babesiosis; the combination of azithromycin and atovaquone also appears promising. Ribavirin has been recently shown to markedly improve survival in patients with Crimean-Congo hemorrhagic fever. The role of antiviral therapy in the treatment of other tick-borne viral infections, including other hemorrhagic fevers and tick-borne encephalitis, is not yet defined.

Keywords

Doxycycline Lyme Disease Atovaquone Babesiosis Spotted Fever 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

Dr Buckingham has given paid speaking engagements for GlaxoSmith-Kline, Sanofi-Aventis, and Abbott Laboratories but does not have a commercial or financial interest in any of the drugs mentioned in this article.

References

  1. 1.
    Sonenshine DE, Azad AF. Ticks and mites in disease transmission. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 992–1003Google Scholar
  2. 2.
    Spach DH, Liles WC, Campbell GL, et al. Tick-borne diseases in the United States. N Engl J Med 1993; 329: 936–47PubMedCrossRefGoogle Scholar
  3. 3.
    American Academy of Pediatrics. Prevention of tick-borne infections. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 186–7Google Scholar
  4. 4.
    McDade JE, Newhouse VF. Natural history of Rickettsia rickettsii. Annu Rev Microbiol 1986; 40: 287–309PubMedCrossRefGoogle Scholar
  5. 5.
    Dalton MJ, Clarke MJ, Holman RC, et al. National surveillance for Rocky Mountain spotted fever, 1981–1992: epidemiologic summary and evaluation of risk factors for fatal outcome. Am J Trop Med Hyg 1995; 52: 405–13PubMedGoogle Scholar
  6. 6.
    Treadwell TA, Holman RC, Clarke MJ, et al. Rocky Mountain spotted fever in the United States, 1993–1996. Am J Trop Med Hyg 2000; 63: 21–6PubMedGoogle Scholar
  7. 7.
    Brouqui P. Tick-borne rickettsioses of the eastern hemisphere. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 438–41Google Scholar
  8. 8.
    Raoult D, Roux V. Rickettsioses as paradigms of new or emerging infectious diseases. Clin Microbiol Rev 1997; 10: 694–719PubMedGoogle Scholar
  9. 9.
    Strickland GT, Olson JG. Ehrlichiosis. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 445–8Google Scholar
  10. 10.
    Jacobs RF. Human monocytic ehrlichiosis: similar to Rocky Mountain spotted fever but different. Pediatr Ann 2002; 31: 180–4PubMedGoogle Scholar
  11. 11.
    Dumler JS, Barbet AF, Bekker CP, et al. Reorganization of genera in the families Rickettsiaceae and Anaplasmataceae in the order Rickettsiales: unification of some species of Ehrlichia with Anaplasma, Cowdria with Ehrlichia and Ehrlichia with Neorickettsia, descriptions of six new species combinations and designation of Ehrlichia equi and ‘HGE agent’ as subjective synonyms of Ehrlichia phagocytophila. Int J Syst Evol Microbiol 2001; 51: 2145–65PubMedCrossRefGoogle Scholar
  12. 12.
    Steere AC. Lyme disease. N Engl J Med 1989; 321: 586–96PubMedCrossRefGoogle Scholar
  13. 13.
    Stechenberg BW. Borrelia (Lyme disease). In: Feigin RD, Cherry JD, editors. Textbook of pediatric infectious diseases. 4th ed. Philadelphia (PA): WB Saunders, 1998: 1522–7Google Scholar
  14. 14.
    Kirkland KB, Klimko TB, Meriwether RA, et al. Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease? Arch Intern Med 1997; 157: 2635–41PubMedCrossRefGoogle Scholar
  15. 15.
    Campbell GL, Paul WS, Schriefer ME, et al. Epidemiologic and diagnostic studies of patients with suspected early Lyme disease, Missouri, 1990–1993. J Infect Dis 1995; 172: 470–80PubMedCrossRefGoogle Scholar
  16. 16.
    Masters E, Granter S, Duray P, et al. Physician-diagnosed erythema migrans and erythema migrans-like rashes following Lone Star tick bites. Arch Dermatol 1998; 134: 955–60PubMedCrossRefGoogle Scholar
  17. 17.
    Felz MW, Chandler Jr FW, Oliver Jr JH, et al. Solitary erythema migrans in Georgia and South Carolina. Arch Dermatol 1999; 135: 1317–26PubMedCrossRefGoogle Scholar
  18. 18.
    James AM, Liveris D, Wormser GP, et al. Borrelia lonestari infection after a bite by an Amblyomma americanum tick. J Infect Dis 2001; 183: 1810–4PubMedCrossRefGoogle Scholar
  19. 19.
    American Academy of Pediatrics. Borrelia (relapsing fever). In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 220–2Google Scholar
  20. 20.
    Butler T. Relapsing fever. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 448–52Google Scholar
  21. 21.
    Parola P, Raoult D. Ticks and tickborne bacterial diseases in humans: an emerging infectious threat [published erratum appears in Clin Infect Dis 2001; 33: 749]. Clin Infect Dis 2001; 32: 897–928PubMedCrossRefGoogle Scholar
  22. 22.
    American Academy of Pediatrics. Tularemia. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 666–7Google Scholar
  23. 23.
    Bryant KA. Tularemia: lymphadenitis with a twist. Pediatr Ann 2002; 31: 187–90PubMedGoogle Scholar
  24. 24.
    American Academy of Pediatrics. Babesiosis. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 211–2Google Scholar
  25. 25.
    Herwaldt BL. Babesiosis. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 688–90Google Scholar
  26. 26.
    Lantos PM, Krause PJ. Babesiosis: similar to malaria but different. Pediatr Ann 2002; 31: 192–7PubMedGoogle Scholar
  27. 27.
    McCormick JB, Fisher-Hoch SP. Crimean-Congo hemorrhagic fever. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 284–7Google Scholar
  28. 28.
    Gritsun TS, Lashkevich VA, Gould EA. Tick-borne encephalitis. Antiviral Res 2003; 57: 129–46PubMedCrossRefGoogle Scholar
  29. 29.
    Aebi C, Tsai TF. Tick-borne encephalitis. In: Feigin RD, Cherry JD, editors. Textbook of pediatric infectious diseases. 4th ed. Philadelphia (PA): WB Saunders, 1998: 2003–8Google Scholar
  30. 30.
    Klasco R. Colorado tick fever. Med Clin North Am 2002; 86: 435–40PubMedCrossRefGoogle Scholar
  31. 31.
    Needham GR. Evaluation of five popular methods for tick removal. Pediatrics 1985; 75: 997–1002PubMedGoogle Scholar
  32. 32.
    Insect repellants. Med Lett Drugs Ther 2003; 45: 41–2Google Scholar
  33. 33.
    Fradin MS. Mosquitoes and mosquito repellants: a clinician’s guide. Ann Intern Med 1998; 128: 931–40PubMedGoogle Scholar
  34. 34.
    American Academy of Pediatrics. Follow safety precautions when using DEET on children [online]. Available from http://www.aap.org/family/wnv-jun03.htm [Accessed 2003 Oct 23]
  35. 35.
    Rolain JM, Maurin M, Vestris G, et al. In vitro susceptibilities of 27 rickettsiae to 13 antimicrobials. Antimicrob Agents Chemother 1998; 42: 1537–41PubMedGoogle Scholar
  36. 36.
    Bradford WD, Hawkins HK. Rocky Mountain spotted fever in childhood. Am J Dis Child 1977; 131: 1228–32PubMedGoogle Scholar
  37. 37.
    Heimick CG, Bernard KW, D’Angelo LJ. Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases. J Infect Dis 1984; 150: 480–8CrossRefGoogle Scholar
  38. 38.
    Buckingham SC. Rocky Mountain spotted fever: a review for the pediatrician. Pediatr Ann 2002; 31: 163–8PubMedGoogle Scholar
  39. 39.
    American Academy of Pediatrics. Rocky Mountain spotted fever. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 532–4Google Scholar
  40. 40.
    Hattwick MAW, Retailliau H, O’Brien RJ, et al. Fatal Rocky Mountain spotted fever. JAMA 1978; 240: 1499–503PubMedCrossRefGoogle Scholar
  41. 41.
    Holman RC, Paddock CD, Curns AT, et al. Analysis of risk factors for fatal Rocky Mountain spotted fever: evidence for superiority of tetracyclines for therapy. J Infect Dis 2001; 184: 1437–44PubMedCrossRefGoogle Scholar
  42. 42.
    Smith M, Unkel JH, Fenton SJ, et al. The use of tetracyclines in pediatric patients. J Pediatr Pharmacol Ther 2001; 6: 66–71Google Scholar
  43. 43.
    Lochary ME, Lockhart PB, Williams WT. Doxycycline and staining of permanent teeth. Pediatr Infect Dis J 1998; 17: 429–31PubMedCrossRefGoogle Scholar
  44. 44.
    Forti G, Benincori C. Doxycycline and the teeth. Lancet 1969; I: 782–3CrossRefGoogle Scholar
  45. 45.
    Anton E, Font B, Munoz T, et al. Clinical and laboratory characteristics of 144 patients with Mediterranean spotted fever. Eur J Clin Microbiol Infect Dis 2003; 22: 126–8PubMedGoogle Scholar
  46. 46.
    Font-Creus B, Bella-Cueto F, Espejo-Arenas E, et al. Mediterranean spotted fever: a cooperative study of 227 cases. Rev Infect Dis 1985; 7: 635–42PubMedCrossRefGoogle Scholar
  47. 47.
    Raoult D, Weiller PJ, Chagnon A, et al. Mediterranean spotted fever: clinical, laboratory and epidemiological features of 199 cases. Am J Trop Med Hyg 1986; 35: 845–50PubMedGoogle Scholar
  48. 48.
    Bella-Cueto F, Font-Creus B, Segura-Porta F, et al. Comparative, randomized trial of one-day doxycycline versus 10-day tetracycline therapy for Mediterranean spotted fever. J Infect Dis 1987; 155: 1056–8PubMedCrossRefGoogle Scholar
  49. 49.
    Ruiz Beltran R, Herrero Herrero JI. Evaluation of ciprofloxacin and doxycycline in the treatment of Mediterranean spotted fever. Eur J Clin Microbiol Infect Dis 1992; 11: 427–31PubMedCrossRefGoogle Scholar
  50. 50.
    Cascio A, Dones P, Romano A, et al. Clinical and laboratory findings of boutonneuse fever in Sicilian children. Eur J Pediatr 1998; 157: 482–6PubMedCrossRefGoogle Scholar
  51. 51.
    Munoz-Espin T, Lopez-Pares P, Espejo-Arenas E, et al. Erythromycin versus tetracycline for treatment of Mediterranean spotted fever. Arch Dis Child 1986; 61: 1027–9PubMedCrossRefGoogle Scholar
  52. 52.
    Bella F, Font B, Uriz S, et al. Randomized trial of doxycycline versus josamycin for Mediterranean spotted fever. Antimicrob Agents Chemother 1990; 34: 937–8PubMedCrossRefGoogle Scholar
  53. 53.
    Meloni G, Meloni T. Azithromycin vs. doxycycline for Mediterranean spotted fever. Pediatr Infect Dis J 1996; 15: 1042–4PubMedCrossRefGoogle Scholar
  54. 54.
    Cascio A, Colomba C, Antinori S, et al. Clarithromycin versus azithromycin in the treatment of Mediterranean spotted fever in children: a randomized controlled trial. Clin Infect Dis 2002; 34: 154–8PubMedCrossRefGoogle Scholar
  55. 55.
    Ruiz Beltran R, Herrero Herrero JI. Deleterious effect of trimethoprim-sulfamethoxazole in Mediterranean spotted fever. Antimicrob Agents Chemother 1992; 36: 1342–3PubMedCrossRefGoogle Scholar
  56. 56.
    Raoult D, Lakos A, Fenollar F, et al. Spotless rickettsiosis caused by Rickettsia slovaca and associated with Dermacentor ticks. Clin Infect Dis 2002; 34: 1331–6PubMedCrossRefGoogle Scholar
  57. 57.
    Maeda K, Markowitz N, Hawley RC, et al. Human infection with Ehrlichia cams, a leukocytic rickettsia. N Engl J Med 1987; 316: 853–6PubMedCrossRefGoogle Scholar
  58. 58.
    Fishbein DB, Dawson JE, Robinson LE. Human ehrlichiosis in the United States, 1985 to 1990. Ann Intern Med 1994; 120: 736–43PubMedGoogle Scholar
  59. 59.
    Jacobs RF, Schutze GE. Ehrlichiosis in children. J Pediatr 1997; 131: 184–92PubMedCrossRefGoogle Scholar
  60. 60.
    American Academy of Pediatrics. Ehrlichiosis. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 266–9Google Scholar
  61. 61.
    Brouqui P, Raoult D. In vitro antibiotic susceptibility of the newly recognized agent of ehrlichiosis in humans, Ehrlichia chaffeensis. Antimicrob Agents Chemother 1992; 36: 2799–803PubMedCrossRefGoogle Scholar
  62. 62.
    Fichtenbaum CJ, Peterson LR, Weil GJ. Ehrlichiosis presenting as a life-threatening illness with features of the toxic shock syndrome. Am J Med 1993; 95: 351–7PubMedCrossRefGoogle Scholar
  63. 63.
    Patel RG, Byrd MA. Near fatal acute respiratory distress syndrome in a patient with human ehrlichiosis. South Med J 1999; 92: 333–5PubMedCrossRefGoogle Scholar
  64. 64.
    Peters TR, Edwards KM, Standaert SM. Severe ehrlichiosis in an adolescent taking trimethoprim-sulfamethoxazole. Pediatr Infect Dis J 2000; 19: 170–2PubMedCrossRefGoogle Scholar
  65. 65.
    Brantley RK. Trimethoprim-sulfamethoxazole and fulminant ehrlichiosis [letter]. Pediatr Infect Dis J 2001; 20: 231PubMedGoogle Scholar
  66. 66.
    Bakken JS, Dumler JS, Chen SM, et al. Human granulocytic ehrlichiosis in the upper midwest United States: a new species emerging? JAMA 1994; 272: 212–8PubMedCrossRefGoogle Scholar
  67. 67.
    Bakken JS, Krueth J, Wilson-Nordskog C, et al. Clinical and laboratory characteristics of human granulocytic ehrlichiosis. JAMA 1996; 275: 199–205PubMedCrossRefGoogle Scholar
  68. 68.
    Maurin M, Bakken JS, Dumler JS. Antibiotic susceptibilities of Anaplasma (Ehrlichia) phagocytophilum strains from various geographic areas in the United States. Antimicrob Agents Chemother 2003; 47: 413–5PubMedCrossRefGoogle Scholar
  69. 69.
    Buitrago MI, Ijdo JW, Rinaudo P, et al. Human granulocytic ehrlichiosis during pregnancy treated successfully with rifampin. Clin Infect Dis 1998; 27: 213–5PubMedCrossRefGoogle Scholar
  70. 70.
    Buller RS, Arens M, Hmiel SP. Ehrlichia ewingii, a newly recognized agent of human ehrlichiosis. N Engl J Med 1999; 341: 148–55PubMedCrossRefGoogle Scholar
  71. 71.
    Storch GA. New developments in tick-borne infections. Pediatr Ann 2002; 31: 200–4PubMedGoogle Scholar
  72. 72.
    American Academy of Pediatrics. Lyme disease. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 407–11Google Scholar
  73. 73.
    Wormser GP, Nadelman RB, Dattwyler RJ, et al. Practice guidelines for the treatment of Lyme disease: the Infectious Diseases Society of America. Clin Infect Dis 2000; 31(1 Suppl.): 1–14PubMedCrossRefGoogle Scholar
  74. 74.
    Terekhova D, Sartakova ML, Wormser GP, et al. Erythromycin resistance in Borrelia burgdorferi. Antimicrob Agents Chemother 2002; 46: 3637–40PubMedCrossRefGoogle Scholar
  75. 75.
    Luft BJ, Dattwyler RJ, Johnson RC, et al. Azithromycin compared with amoxicillin in the treatment of erythema migrans: a double-blind, randomized, controlled trial. Ann Intern Med 1996; 124: 785–91PubMedGoogle Scholar
  76. 76.
    Eppes SC, Childs JA. Comparative study of cefuroxime axetil versus amoxicillin in children with early Lyme disease. Pediatrics 2002; 109: 1173–7PubMedCrossRefGoogle Scholar
  77. 77.
    Klempner MS, Hu LT, Evans J, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med 2001; 345: 85–92PubMedCrossRefGoogle Scholar
  78. 78.
    Patel R, Grogg KL, Edwards WD, et al. Death from inappropriate therapy for Lyme disease. Clin Infect Dis 2000; 31: 1107–9PubMedCrossRefGoogle Scholar
  79. 79.
    Hayes EB, Piesman J. How can we prevent Lyme disease? N Engl J Med 2003; 348: 2424–30PubMedCrossRefGoogle Scholar
  80. 80.
    Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med 2001; 345: 79–84PubMedCrossRefGoogle Scholar
  81. 81.
    Dworkin MS, Anderson DE, Schwan TG, et al. Tick-borne relapsing fever in the northwestern United States and southwestern Canada. Clin Infect Dis 1998; 26: 122–31PubMedCrossRefGoogle Scholar
  82. 82.
    Stewart SJ. Francisella. In: Murray PR, editor. Manual of clinical microbiology. Washington (DC): ASM Press, 1995: 545–8Google Scholar
  83. 83.
    Enderlin G, Morales L, Jacobs RF, et al. Streptomycin and alternative agents for the treatment of tularemia: review of the literature. Clin Infect Dis 1994; 19: 42–7PubMedCrossRefGoogle Scholar
  84. 84.
    Cross JT, Schutze GE, Jacobs RF. Treatment of tularemia with gentamicin in pediatric patients. Pediatr Infect Dis J 1995; 14: 151–2PubMedCrossRefGoogle Scholar
  85. 85.
    Johansson A, Berglund L, Sjostedt A, et al. Ciprofloxacin for treatment of tularemia [letter]. Clin Infect Dis 2001; 33: 267–8PubMedCrossRefGoogle Scholar
  86. 86.
    Johansson A, Berglund L, Gothefors L, et al. Ciprofloxacin for treatment of tularemia in children. Pediatr Infect Dis J 2000; 19: 449–53PubMedCrossRefGoogle Scholar
  87. 87.
    Limaye AP, Hooper CJ. Treatment of tularemia with fluoroquinolones: two cases and review. Clin Infect Dis 1999; 29: 922–4PubMedCrossRefGoogle Scholar
  88. 88.
    American Academy of Pediatrics. Fluroquinolones. In: Pickering LK, editor. 2003 Red Book: Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village (IL): American Academy of Pediatrics, 2003: 693–4Google Scholar
  89. 89.
    Krause PJ, Lepore T, Sikand VK, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med 2000; 343: 1454–8PubMedCrossRefGoogle Scholar
  90. 90.
    Raoult D, Soulayrol L, Toga B, et al. Babesiosis, pentamidine, and cotrimoxazole [letter]. Ann Intern Med 1987; 107: 944PubMedGoogle Scholar
  91. 91.
    Fisher-Hoch SP, Khan JK, Rehman S, et al. Crimean-Congo hemorrhagic fever treated with oral ribavirin. Lancet 1995; 346: 472–5PubMedCrossRefGoogle Scholar
  92. 92.
    Van de Wal BW, Joubert JR, Van Eeden PJ, et al. A nosocomial outbreak of Crimean-Congo hemorrhagic fever at Tygerberg Hospital: IV. Preventive and prophylactic measures. S Afr Med J 1985; 68: 729–32PubMedGoogle Scholar
  93. 93.
    Mardani M, Jahromi MK, Naieni KH, et al. The efficacy of oral ribavirin in the treatment of Crimean-Congo hemorrhagic fever in Iran. Clin Infect Dis 2003; 36: 1613–8PubMedCrossRefGoogle Scholar
  94. 94.
    Tsai T. Kyasanur forest disease. In: Strickland GT, editor. Hunter’s tropical medicine. 8th ed. Philadelphia (PA): WB Saunders, 2000: 293–5Google Scholar
  95. 95.
    Crance JM, Scaramozzino N, Jouan A, et al. Interferon, ribavirin, 6-azauridine and glycyrrhizin: antiviral compounds active against pathogenic flaviviruses. Antiviral Res 2003; 58: 73–9PubMedCrossRefGoogle Scholar
  96. 96.
    Smee DF, Sidwell RW, Clark SM, et al. Inhibition of bluetongue and Colorado tick fever orbiviruses by selected antiviral substances. Antimicrob Agents Chemother 1981; 20: 533–8PubMedCrossRefGoogle Scholar

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© Adis Data Information BV 2005

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of Infectious DiseaseUniversity of Tennessee Health Science Center and Children’s Foundation Research Center at West Tower, Le Bonheur Children’s Medical CenterMemphisUSA

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