Colonización por Pneumocystis jirovecii en la enfermedad pulmonar obstructiva crónica
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jul 26, 2018
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Resumen
La enfermedad pulmonar obstructiva crónica (EPOC) es una enfermedad prevalente en la población colombiana, que característicamente tiene un deterioro progresivo y altera la calidad de vida de los pacientes. Solo del 15% al 20% de los pacientes con antecedente de tabaquismo desarrollan la enfermedad, por lo que factores ambientales y genéticos adicionales influyen en su progresión. De las causas infecciosas que han tomado importancia, el Pneumocystis jirovecii, un hongo ubicuo que entra en contacto con la vía aérea de los humanos desde la infancia, es causa de neumonía en pacientes inmunosuprimidos. Se han descrito tasas elevadas de colonización en pacientes con EPOC, que aumentan con la severidad de la enfermedad. EPOC e infección por P. jirovecii parecen compartir una respuesta inmunológica similar, lo cual podría explicar el papel de la
colonización por el hongo en su progresión y gravedad.
Keywords
Pneumocystis jirovecii ; pulmonary disease chronic obstructive; immunology.Pneumocystis jirovecii ; enfermedad pulmonar obstructiva crónica; inmunología
References
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3. Collaborators GBDDaH. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet (London, England). 2016;388(10053):1603-58.
4. Vestbo J, Hurd SS, Agusti AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir
Crit Care Med. 2013;187(4):347-65.
5. Vestbo J, Hurd SS, Rodriguez-Roisin R. The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD)--why and what? Clin Respir J. 2012;6(4):208-14.
6. Morris A, Norris KA. Colonization by Pneumocystis jirovecii and its role in disease. Clin Microbiol Rev. 2012;25(2):297-317.
7. Thomas CF, Jr., Limper AH. Current insights into the biology and pathogenesis of Pneumocystis pneumonia. Nat Rev Microbiol. 2007;5(4):298-308.
8. Calderón Sandubete E, de Armas Rodríguez Y, Capo de Paz V. Pneumocystis jirovecii: one hundred years of history. Rev Cubana Med Trop. 2011;63(2):97-116.
9. Frenkel JK. Pneumocystis jiroveci n. sp. from man: Morphology, physiology, and immunology in relation to pathology. National Cancer Institute Monograph. 1976;43:13-30.
10. Mazars E, Dei-Cas E. Epidemiological and taxonomic impact of Pneumocystis biodiversity. FEMS immunology and medical microbiology. 1998;22(1-2):75-80.
11. Sloand E, Laughon B, Armstrong M, Bartlett MS, Blumenfeld W, Cushion M, et al. The challenge of Pneumocystis carinii culture. J Eukariot Microbiol. 1993;40(2):188-95.
12. Aliouat-Denis CM, Martínez A, Aliouat el M, Pottier M, Gantois N, Dei-Cas E. The Pneumocystis life cycle. Memorias do Instituto Oswaldo Cruz. 2009;104(3):419-26.
13. Burgess JW, Kottom TJ, Limper AH. Pneumocystis carinii exhibits a conserved meiotic control pathway. Infect Immun. 2008;76(1):417-25.
14. Kottom TJ, Kennedy CC, Limper AH. Pneumocystis PCINT1, a molecule with integrin-like features that mediates organism adhesion to fibronectin. Mol Microbiol. 2008;67(4):747-61.
15. Ambrose HE, Keely SP, Aliouat EM, Dei-Cas E, Wakefield AE, Miller RF, et al. Expression and complexity of the PRT1 multigene family of Pneumocystis carinii. Microbiology (Reading, England). 2004;150(Pt 2):293-300.
16. Stringer JR, Cushion MT. The genome of Pneumocystis carinii. FEMS Immunology and Medical Microbiology. 1998;22(1-2):15-26.
17. Dumoulin A, Mazars E, Seguy N, Gargallo-Viola D, Vargas S, Cailliez JC, et al. Transmission of Pneumocystis carinii disease from immunocompetent contacts of infected hosts to susceptible hosts. Eur J Clin Microbil Infet
Dis. 2000;19(9):671-8.
18. Hauser PM, Nahimana A, Taffe P, Weber R, Francioli P, Bille J, et al. Interhuman transmission as a potential key parameter for geographical variation in the prevalence of Pneumocystis jirovecii dihydropteroate synthase
mutations. Clin infect Dis. 2010;51(4):e28-33.
19. Kovacs JA, Masur H. Evolving health effects of Pneumocystis: one hundred years of progress in diagnosis and treatment. JAMA. 2009;301(24):2578-85.
20. Kelly MN, Shellito JE. Current understanding of Pneumocystis immunology. Future Microbiol. 2010;5(1):43-65.
21. Iriart X, Witkowski B, Courtais C, Abbes S, Tkaczuk J, Courtade M, et al. Cellular and cytokine changes in the alveolar environment among immunocompromised patients during Pneumocystis jirovecii infection. Med
Mycol. 2010;48(8):1075-87.
22. Fitzpatrick ME, Tedrow JR, Hillenbrand ME, Lucht L, Richards T, Norris KA, et al. Pneumocystis jirovecii colonization is associated with enhanced Th1 inflammatory gene expression in lungs of humans with chronic
obstructive pulmonary disease. Microbiol Immunol. 2014;58(3):202-11.
23. Mekinian A, Durand-Joly I, Hatron PY, Moranne O, Denis G, Dei-Cas E, et al. Pneumocystis jirovecii colonization in patients with systemic autoimmune diseases: prevalence, risk factors of colonization and outcome. Rheumatology (Oxford, England). 2011;50(3):569-77.
24. Sheikholeslami MF, Sadraei J, Farnia P, Forozandeh M, Emadi Kochak H, Tabarsi P, et al. Colonization of Pneumocystis jirovecii in Chronic Obstructive Pulmonary Disease (COPD) patients and the rate of Pneumocystis pneumonia in Iranian non-HIV(+) immunocompromised patients. Iran J Microbiol. 2013;5(4):411-7.
25. Respaldiza N, Medrano FJ, Medrano AC, Varela JM, de la Horra C, Montes-Cano M, et al. High seroprevalence of Pneumocystis infection in Spanish children. Clin Microbiol Infect. 2004;10(11):1029-31.
26. Vargas SL, Ponce CA, Galvez P, Ibarra C, Haas EA, Chadwick AE, et al. Pneumocystis is not a direct cause of sudden infant death syndrome. Pediatr Infect Dis J. 2007;26(1):81-3.
27. Vargas SL, Ponce CA, Luchsinger V, Silva C, Gallo M, Lopez R, et al. Detection of Pneumocystis carinii f. sp. hominis and viruses in presumably immunocompetent infants who died in the hospital or in the community. J Infect Dis. 2005;191(1):122-6.
28. Medrano FJ, Montes-Cano M, Conde M, de la Horra C, Respaldiza N, Gasch A, et al. Pneumocystis jirovecii in general population. Emerg Infect Dis. 2005;11(2):245-50.
29. Ponce CA, Gallo M, Bustamante R, Vargas SL. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis. 2010;50(3):347-53.
30. Huang L, Crothers K, Morris A, Groner G, Fox M, Turner JR, et al. Pneumocystis colonization in HIV-infected patients. J Eukariot Microbiol. 2003;50 Suppl:616-7.
31. Gutiérrez S, Morilla R, León JA, Martín-Garrido I, Rivero L, Friaza V, et al. High prevalence of Pneumocystis jiroveci colonization among young HIV-infected patients. J Adolesc Health.. 2011;48(1):103-5.
32. Morris A, Kingsley LA, Groner G, Lebedeva IP, Beard CB, Norris KA. Prevalence and clinical predictors of Pneumocystis colonization among HIV-infected men. AIDS (London, England). 2004;18(5):793-8.
33. Probst M, Ries H, Schmidt-Wieland T, Serr A. Detection of Pneumocystis carinii DNA in patients with chronic lung diseases. Eur J Clin Microbiol Infect Dis. 2000;19(8):644-5.
34. Respaldiza N, Montes-Cano MA, Dapena FJ, de la Horra C, Mateos I, Medrano FJ, et al. Prevalence of colonisation and genotypic characterisation of Pneumocystis jirovecii among cystic fibrosis patients in Spain. Clin Microbiol Infect. 2005;11(12):1012-5.
35. Gal SL, Hery-Arnaud G, Ramel S, Virmaux M, Damiani C, Totet A, et al. Pneumocystis jirovecii and cystic fibrosis in France. Scand J Infect Dis. 2010;42(3):225-7.
36. Calderón EJ, Regordan C, Medrano FJ, Ollero M, Varela JM. Pneumocystis carinii infection in patients with chronic bronchial disease. Lancet. 1996;347(9006):977.
37. Vidal S, de la Horra C, Martín J, Montes-Cano MA, Rodríguez E, Respaldiza N, et al. Pneumocystis jirovecii colonisation in patients with interstitial lung disease. Clin Microbiol Infect. 2006;12(3):231-5.
38. Wang DD, Zheng MQ, Zhang N, An CL. Investigation of Pneumocystis jirovecii colonization in patients with chronic pulmonary diseases in the People's Republic of China. Int J Chron Obstruct Pulmon Dis. 2015;10:2079-85.
39. Calderón EJ, Rivero L, Respaldiza N, Morilla R, Montes-Cano MA, Friaza V, et al. Systemic inflammation in patients with chronic obstructive pulmonary disease who are colonized with Pneumocystis jiroveci. Clin Infect Dis. 2007;45(2):e17-9.
40. Calderón E, de la Horra C, Medrano FJ, López-Suárez A, Montes-Cano MA, Respaldiza N, et al. Pneumocystis jiroveci isolates with dihydropteroate synthase mutations in patients with chronic bronchitis. Eur J Clin Microbiol Infect Dis. 2004;23(7):545-9.
41. Morris A, Wei K, Afshar K, Huang L. Epidemiology and clinical significance of pneumocystis colonization. J Infect Dis. 2008;197(1):10-7.
42. Kling HM, Shipley TW, Guyach S, Tarantelli R, Morris A, Norris KA. Trimethoprim-sulfamethoxazole treatment does not reverse obstructive pulmonary changes in pneumocystis-colonized nonhuman primates with SHIV infection. J Acquir Inmune Defic Syndr. 2014;65(4):381-9.
43. Fitzpatrick ME, Tedrow JR, Hillenbrand ME, Lucht L, Richards T, Norris KA, et al. Pneumocystis jirovecii colonization is associated with enhanced Th1 inflammatory gene expression in lungs of humans with chronic obstructive pulmonary disease. Microbiol Immun. 2014;58(3):202-11.
44. Morris A, Alexander T, Radhi S, Lucht L, Sciurba FC, Kolls JK, et al. Airway obstruction is increased in pneumocystis-colonized human immunodeficiency virus-infected outpatients. J Clin Microbiol. 2009;47(11):3773-6.
45. Morris A, Sciurba FC, Lebedeva IP, Githaiga A, Elliott WM, Hogg JC, et al. Association of chronic obstructive pulmonary disease severity and Pneumocystis colonization. Am J Respir Crit Care Med. 2004;170(4):408-13.
46. Cosio MG, Saetta M, Agusti A. Immunologic aspects of chronic obstructive pulmonary disease. N Engl J Med. 2009;360(23):2445-54.
47. Shipley TW, Kling HM, Morris A, Patil S, Kristoff J, Guyach SE, et al. Persistent pneumocystis colonization leads to the development of chronic obstructive pulmonary disease in a nonhuman primate model of AIDS. J Infect Dis. 2010;202(2):302-12.
48. Sivam S, Sciurba FC, Lucht LA, Zhang Y, Duncan SR, Norris KA, et al. Distribution of Pneumocystis jirovecii in lungs from colonized COPD patients. Diagn Microbiol Infect Dis. 2011;71(1):24-8.
49. Khodavaisy S, Mortaz E, Mohammadi F, Aliyali M, et al. Pneumocystis jirovecii colonization in Chronic Obstructive Pulmonary Disease (COPD). Curr Med Mycol. 2015;1(1):42-8.
50. Norris KA, Morris A. Pneumocystis infection and the pathogenesis of chronic obstructive pulmonary disease. Immun Res. 2011;50(2-3):175-80.
51. Morris A, Netravali M, Kling HM, Shipley T, Ross T, Sciurba FC, et al. Relationship of pneumocystis antibody response to severity of chronic obstructive pulmonary disease. Clin Infect Dis. 2008;47(7):e64-8.
2. Caballero A, Torres-Duque CA, Jaramillo C, Bolívar F, Sanabria F, Osorio P, et al. Prevalence of COPD in five Colombian cities situated at low, medium, and high altitude (PREPOCOL study). Chest. 2008;133(2):343-9.
3. Collaborators GBDDaH. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet (London, England). 2016;388(10053):1603-58.
4. Vestbo J, Hurd SS, Agusti AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir
Crit Care Med. 2013;187(4):347-65.
5. Vestbo J, Hurd SS, Rodriguez-Roisin R. The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD)--why and what? Clin Respir J. 2012;6(4):208-14.
6. Morris A, Norris KA. Colonization by Pneumocystis jirovecii and its role in disease. Clin Microbiol Rev. 2012;25(2):297-317.
7. Thomas CF, Jr., Limper AH. Current insights into the biology and pathogenesis of Pneumocystis pneumonia. Nat Rev Microbiol. 2007;5(4):298-308.
8. Calderón Sandubete E, de Armas Rodríguez Y, Capo de Paz V. Pneumocystis jirovecii: one hundred years of history. Rev Cubana Med Trop. 2011;63(2):97-116.
9. Frenkel JK. Pneumocystis jiroveci n. sp. from man: Morphology, physiology, and immunology in relation to pathology. National Cancer Institute Monograph. 1976;43:13-30.
10. Mazars E, Dei-Cas E. Epidemiological and taxonomic impact of Pneumocystis biodiversity. FEMS immunology and medical microbiology. 1998;22(1-2):75-80.
11. Sloand E, Laughon B, Armstrong M, Bartlett MS, Blumenfeld W, Cushion M, et al. The challenge of Pneumocystis carinii culture. J Eukariot Microbiol. 1993;40(2):188-95.
12. Aliouat-Denis CM, Martínez A, Aliouat el M, Pottier M, Gantois N, Dei-Cas E. The Pneumocystis life cycle. Memorias do Instituto Oswaldo Cruz. 2009;104(3):419-26.
13. Burgess JW, Kottom TJ, Limper AH. Pneumocystis carinii exhibits a conserved meiotic control pathway. Infect Immun. 2008;76(1):417-25.
14. Kottom TJ, Kennedy CC, Limper AH. Pneumocystis PCINT1, a molecule with integrin-like features that mediates organism adhesion to fibronectin. Mol Microbiol. 2008;67(4):747-61.
15. Ambrose HE, Keely SP, Aliouat EM, Dei-Cas E, Wakefield AE, Miller RF, et al. Expression and complexity of the PRT1 multigene family of Pneumocystis carinii. Microbiology (Reading, England). 2004;150(Pt 2):293-300.
16. Stringer JR, Cushion MT. The genome of Pneumocystis carinii. FEMS Immunology and Medical Microbiology. 1998;22(1-2):15-26.
17. Dumoulin A, Mazars E, Seguy N, Gargallo-Viola D, Vargas S, Cailliez JC, et al. Transmission of Pneumocystis carinii disease from immunocompetent contacts of infected hosts to susceptible hosts. Eur J Clin Microbil Infet
Dis. 2000;19(9):671-8.
18. Hauser PM, Nahimana A, Taffe P, Weber R, Francioli P, Bille J, et al. Interhuman transmission as a potential key parameter for geographical variation in the prevalence of Pneumocystis jirovecii dihydropteroate synthase
mutations. Clin infect Dis. 2010;51(4):e28-33.
19. Kovacs JA, Masur H. Evolving health effects of Pneumocystis: one hundred years of progress in diagnosis and treatment. JAMA. 2009;301(24):2578-85.
20. Kelly MN, Shellito JE. Current understanding of Pneumocystis immunology. Future Microbiol. 2010;5(1):43-65.
21. Iriart X, Witkowski B, Courtais C, Abbes S, Tkaczuk J, Courtade M, et al. Cellular and cytokine changes in the alveolar environment among immunocompromised patients during Pneumocystis jirovecii infection. Med
Mycol. 2010;48(8):1075-87.
22. Fitzpatrick ME, Tedrow JR, Hillenbrand ME, Lucht L, Richards T, Norris KA, et al. Pneumocystis jirovecii colonization is associated with enhanced Th1 inflammatory gene expression in lungs of humans with chronic
obstructive pulmonary disease. Microbiol Immunol. 2014;58(3):202-11.
23. Mekinian A, Durand-Joly I, Hatron PY, Moranne O, Denis G, Dei-Cas E, et al. Pneumocystis jirovecii colonization in patients with systemic autoimmune diseases: prevalence, risk factors of colonization and outcome. Rheumatology (Oxford, England). 2011;50(3):569-77.
24. Sheikholeslami MF, Sadraei J, Farnia P, Forozandeh M, Emadi Kochak H, Tabarsi P, et al. Colonization of Pneumocystis jirovecii in Chronic Obstructive Pulmonary Disease (COPD) patients and the rate of Pneumocystis pneumonia in Iranian non-HIV(+) immunocompromised patients. Iran J Microbiol. 2013;5(4):411-7.
25. Respaldiza N, Medrano FJ, Medrano AC, Varela JM, de la Horra C, Montes-Cano M, et al. High seroprevalence of Pneumocystis infection in Spanish children. Clin Microbiol Infect. 2004;10(11):1029-31.
26. Vargas SL, Ponce CA, Galvez P, Ibarra C, Haas EA, Chadwick AE, et al. Pneumocystis is not a direct cause of sudden infant death syndrome. Pediatr Infect Dis J. 2007;26(1):81-3.
27. Vargas SL, Ponce CA, Luchsinger V, Silva C, Gallo M, Lopez R, et al. Detection of Pneumocystis carinii f. sp. hominis and viruses in presumably immunocompetent infants who died in the hospital or in the community. J Infect Dis. 2005;191(1):122-6.
28. Medrano FJ, Montes-Cano M, Conde M, de la Horra C, Respaldiza N, Gasch A, et al. Pneumocystis jirovecii in general population. Emerg Infect Dis. 2005;11(2):245-50.
29. Ponce CA, Gallo M, Bustamante R, Vargas SL. Pneumocystis colonization is highly prevalent in the autopsied lungs of the general population. Clin Infect Dis. 2010;50(3):347-53.
30. Huang L, Crothers K, Morris A, Groner G, Fox M, Turner JR, et al. Pneumocystis colonization in HIV-infected patients. J Eukariot Microbiol. 2003;50 Suppl:616-7.
31. Gutiérrez S, Morilla R, León JA, Martín-Garrido I, Rivero L, Friaza V, et al. High prevalence of Pneumocystis jiroveci colonization among young HIV-infected patients. J Adolesc Health.. 2011;48(1):103-5.
32. Morris A, Kingsley LA, Groner G, Lebedeva IP, Beard CB, Norris KA. Prevalence and clinical predictors of Pneumocystis colonization among HIV-infected men. AIDS (London, England). 2004;18(5):793-8.
33. Probst M, Ries H, Schmidt-Wieland T, Serr A. Detection of Pneumocystis carinii DNA in patients with chronic lung diseases. Eur J Clin Microbiol Infect Dis. 2000;19(8):644-5.
34. Respaldiza N, Montes-Cano MA, Dapena FJ, de la Horra C, Mateos I, Medrano FJ, et al. Prevalence of colonisation and genotypic characterisation of Pneumocystis jirovecii among cystic fibrosis patients in Spain. Clin Microbiol Infect. 2005;11(12):1012-5.
35. Gal SL, Hery-Arnaud G, Ramel S, Virmaux M, Damiani C, Totet A, et al. Pneumocystis jirovecii and cystic fibrosis in France. Scand J Infect Dis. 2010;42(3):225-7.
36. Calderón EJ, Regordan C, Medrano FJ, Ollero M, Varela JM. Pneumocystis carinii infection in patients with chronic bronchial disease. Lancet. 1996;347(9006):977.
37. Vidal S, de la Horra C, Martín J, Montes-Cano MA, Rodríguez E, Respaldiza N, et al. Pneumocystis jirovecii colonisation in patients with interstitial lung disease. Clin Microbiol Infect. 2006;12(3):231-5.
38. Wang DD, Zheng MQ, Zhang N, An CL. Investigation of Pneumocystis jirovecii colonization in patients with chronic pulmonary diseases in the People's Republic of China. Int J Chron Obstruct Pulmon Dis. 2015;10:2079-85.
39. Calderón EJ, Rivero L, Respaldiza N, Morilla R, Montes-Cano MA, Friaza V, et al. Systemic inflammation in patients with chronic obstructive pulmonary disease who are colonized with Pneumocystis jiroveci. Clin Infect Dis. 2007;45(2):e17-9.
40. Calderón E, de la Horra C, Medrano FJ, López-Suárez A, Montes-Cano MA, Respaldiza N, et al. Pneumocystis jiroveci isolates with dihydropteroate synthase mutations in patients with chronic bronchitis. Eur J Clin Microbiol Infect Dis. 2004;23(7):545-9.
41. Morris A, Wei K, Afshar K, Huang L. Epidemiology and clinical significance of pneumocystis colonization. J Infect Dis. 2008;197(1):10-7.
42. Kling HM, Shipley TW, Guyach S, Tarantelli R, Morris A, Norris KA. Trimethoprim-sulfamethoxazole treatment does not reverse obstructive pulmonary changes in pneumocystis-colonized nonhuman primates with SHIV infection. J Acquir Inmune Defic Syndr. 2014;65(4):381-9.
43. Fitzpatrick ME, Tedrow JR, Hillenbrand ME, Lucht L, Richards T, Norris KA, et al. Pneumocystis jirovecii colonization is associated with enhanced Th1 inflammatory gene expression in lungs of humans with chronic obstructive pulmonary disease. Microbiol Immun. 2014;58(3):202-11.
44. Morris A, Alexander T, Radhi S, Lucht L, Sciurba FC, Kolls JK, et al. Airway obstruction is increased in pneumocystis-colonized human immunodeficiency virus-infected outpatients. J Clin Microbiol. 2009;47(11):3773-6.
45. Morris A, Sciurba FC, Lebedeva IP, Githaiga A, Elliott WM, Hogg JC, et al. Association of chronic obstructive pulmonary disease severity and Pneumocystis colonization. Am J Respir Crit Care Med. 2004;170(4):408-13.
46. Cosio MG, Saetta M, Agusti A. Immunologic aspects of chronic obstructive pulmonary disease. N Engl J Med. 2009;360(23):2445-54.
47. Shipley TW, Kling HM, Morris A, Patil S, Kristoff J, Guyach SE, et al. Persistent pneumocystis colonization leads to the development of chronic obstructive pulmonary disease in a nonhuman primate model of AIDS. J Infect Dis. 2010;202(2):302-12.
48. Sivam S, Sciurba FC, Lucht LA, Zhang Y, Duncan SR, Norris KA, et al. Distribution of Pneumocystis jirovecii in lungs from colonized COPD patients. Diagn Microbiol Infect Dis. 2011;71(1):24-8.
49. Khodavaisy S, Mortaz E, Mohammadi F, Aliyali M, et al. Pneumocystis jirovecii colonization in Chronic Obstructive Pulmonary Disease (COPD). Curr Med Mycol. 2015;1(1):42-8.
50. Norris KA, Morris A. Pneumocystis infection and the pathogenesis of chronic obstructive pulmonary disease. Immun Res. 2011;50(2-3):175-80.
51. Morris A, Netravali M, Kling HM, Shipley T, Ross T, Sciurba FC, et al. Relationship of pneumocystis antibody response to severity of chronic obstructive pulmonary disease. Clin Infect Dis. 2008;47(7):e64-8.
Cómo citar
Cañas Arboleda, A., Garzón Herazo, J. R., Hernández Florez, C., Cita Pardo, J. E., Burbano, F., & Parra Giraldo, C. M. (2018). Colonización por Pneumocystis jirovecii en la enfermedad pulmonar obstructiva crónica. Universitas Medica, 59(3), 1–12. https://doi.org/10.11144/Javeriana.umed59-3.pneu
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