Algorithm for diagnosis of primary vasculitides

Algoritmo diagnóstico de vasculites primárias

Alexandre Sacchetti Bezerra Afonso César Polimanti Rafael Vilhena de Carvalho Fürst João Antônio Corrêa About the authors

Abstract

Primary vasculitides are diseases with a wide variety of anatomical, clinical, radiological, and laboratory presentations. Primary vasculitides are difficult to diagnose because of the complexity of clinical presentation, which may lead to delayed treatment and increased financial costs of workup investigations involving non-essential tests. Our objective in the present study is to create an algorithm that helps diagnosis of Primary vasculitides. The algorithm presented in this article allows fast, simple and cost-effective diagnosis of primary vasculitides using just clinical concepts and a few laboratory tests.

Keywords:
algorithms; classification; diagnosis, differential; systemic vasculitis; vasculitis

Resumo

As vasculites primárias são doenças que possuem apresentações anatômicas, clínicas, radiológicas e laboratoriais muito distintas. Em virtude da complexidade dos quadros clínicos apresentados, as vasculites primárias são de difícil diagnóstico, o que pode promover um retardo no início da terapêutica, além de aumentar os custos financeiros da investigação propedêutica com exames não essenciais. O objetivo deste estudo foi criar um algoritmo que auxilie o diagnóstico das vasculites primárias. O algoritmo apresentado neste artigo permite a realização de diagnóstico rápido, simples e de baixo custo nas vasculites primárias, com a utilização de alguns conceitos clínicos e poucos exames laboratoriais.

Palavras-chave:
algoritmos; classificação; diagnóstico diferencial; vasculite sistêmica; vasculite

INTRODUCTION

Vasculitides can be defined as conditions in which an inflammatory process is evident in the vessel wall, associated with target organ damage. 11 Criado PR, Marques GF, Morita TC, Carvalho JF. Epidemiological, clinical and laboratory profiles of cutaneous polyarteritis nodosa patients: report of 22 cases and literature review. Autoimmun Rev. 2016;15(6):558-63. http://dx.doi.org/10.1016/j.autrev.2016.02.010. PMid:26876385.
http://dx.doi.org/10.1016/j.autrev.2016...
Their annual incidence has been increasing over the years. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...

To date, the literature on the subject does not provide a consensus on the best way to define, classify, and diagnose vasculitis. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,33 Alberti-Violetti S, Berti E, Marzano AV. Cutaneous and systemic vasculitides in dermatology: a histological perspective. G Ital Dermatol Venereol. 2018;153(2):185-93. PMid:29368866.

Vasculitides are classified as primary vasculitides (PV) or secondary vasculitides (SV). 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...

Secondary vasculitides are caused by other diseases, which are considered their etiologies. Thus, a multitude of diseases may induce secondary vasculitis. Cancer, trauma, systemic lupus erythematosus, rheumatoid arthritis, and rocky mountain spotted fever are some of the many examples of diseases that can trigger secondary vasculitis. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,44 Ramos-Casals M, Stone JH, Cid MC, Bosch X. The cryoglobulinaemias. Lancet. 2012;379(9813):348-60. http://dx.doi.org/10.1016/S0140-6736(11)60242-0. PMid:21868085.
http://dx.doi.org/10.1016/S0140-6736(11...

Primary vasculitides are characterized by immunological modulation failure, 55 Brandt HR, Arnone M, Valente NY, Criado PR, Sotto MN. Vasculite cutânea de pequenos vasos: etiologia, patogênese, classificação e critérios diagnósticos - Parte I. An Bras Dermatol. 2007;82(5):387-406. http://dx.doi.org/10.1590/S0365-05962007000500002.
http://dx.doi.org/10.1590/S0365-0596200...
with no definite etiology, and patients usually present with consumptive syndrome. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...

The objective of this study was to create an algorithm to aid diagnosis of primary vasculitides.

The classification recommended by the American College of Rheumatology, published in 1994 and revised in 2012 in the Chapel Hill Consensus (CHC2012), organizes Primary and secondary vasculitis based on the size of the vessel involved. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,66 Jennette JC, Falk RJ, Andrassy K, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 1994;37(2):187-92. http://dx.doi.org/10.1002/art.1780370206. PMid:8129773.
http://dx.doi.org/10.1002/art.178037020...
The scientific relevance of these consensuses has standardized articles on the subject.

In order to facilitate diagnostic investigation of primary vasculitides, we also grouped diseases based on vessel caliber, as shown in Table 1 .

Table 1
Names of vasculitides classified by vessel caliber.

It is vital that the physician look for the signs and symptoms already established by CHC2012 when conducting diagnostic screening of primary vasculitides of large and medium vessels. 11 Criado PR, Marques GF, Morita TC, Carvalho JF. Epidemiological, clinical and laboratory profiles of cutaneous polyarteritis nodosa patients: report of 22 cases and literature review. Autoimmun Rev. 2016;15(6):558-63. http://dx.doi.org/10.1016/j.autrev.2016.02.010. PMid:26876385.
http://dx.doi.org/10.1016/j.autrev.2016...
,22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,66 Jennette JC, Falk RJ, Andrassy K, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 1994;37(2):187-92. http://dx.doi.org/10.1002/art.1780370206. PMid:8129773.
http://dx.doi.org/10.1002/art.178037020...

Table 2 lists the main clinical characteristics of primary vasculitides of large and medium vessels.

Table 2
Names and definitions of vasculitis of large and medium caliber vessels.

Our algorithm, shown in Figure 1 , does not recommend laboratory tests in the diagnostic routine for primary vasculitides of large and medium vessels, since the clinical characteristics of the four diseases involved are sufficient. 77 Kallenberg CGM, Brouwer E, Weening JJ, Cohen Tervaert JW. Anti-neutrophil cytoplasmic antibodies: current diagnostic and pathophysiological potential. Kidney Int. 1994;46(1):1-15. http://dx.doi.org/10.1038/ki.1994.239. PMid:7933826.
http://dx.doi.org/10.1038/ki.1994.239 ...

8 Burns JC, Glodé MP. Kawasaki syndrome. Lancet. 2004;364(9433):533-44. http://dx.doi.org/10.1016/S0140-6736(04)16814-1. PMid:15302199.
http://dx.doi.org/10.1016/S0140-6736(04...

9 Niederkohr RD, Levin LA. Management of the patient with suspected temporal arteritis a decision-analytic approach. Ophthalmol. 2005;112(5):744-56. http://dx.doi.org/10.1016/j.ophtha.2005.01.031. PMid:15878052.
http://dx.doi.org/10.1016/j.ophtha.2005...

10 Mason JC. Takayasu arteritis--advances in diagnosis and management. Nat Rev Rheumatol. 2010;6(7):406-15. http://dx.doi.org/10.1038/nrrheum.2010.82. PMid:20596053.
http://dx.doi.org/10.1038/nrrheum.2010....
-1111 Serra R, Butrico L, Fugetto F, et al. Updates in pathophysiology, diagnosis and management of Takayasu Arteritis. Ann Vasc Surg. 2016;35:210-25. http://dx.doi.org/10.1016/j.avsg.2016.02.011. PMid:27238990.
http://dx.doi.org/10.1016/j.avsg.2016.0...

Figure 1
Diagnostic algorithm for primary vasculitides.

For primary vasculitis of small vessels, we advise judicious and economical test ordering.

In addition to benefiting the patient, wise diagnostic investigation hastens specific therapy and is less of a burden on health services. Tables 3 and 4 list costs of commonly ordered tests for diagnostic investigation of vasculitis in the United States and on the Brazilian Public Healthcare Service, respectively.

Table 3
Costs of some tests for primary vasculitis diagnostic screening in United States.
Table 4
Costs of some tests for primary vasculitis diagnostic screening in Brazil.

It is a myth that diagnosis can be speeded up in cases of primary vasculitis of small vessels that are suitable for non-noble tissue biopsies. 33 Alberti-Violetti S, Berti E, Marzano AV. Cutaneous and systemic vasculitides in dermatology: a histological perspective. G Ital Dermatol Venereol. 2018;153(2):185-93. PMid:29368866.

Since biopsy is expensive, difficult to perform and inconclusive in a large number of patients with small vessel vasculitis, we recommend a quick and staged sequence of laboratory tests ( Figure 1 ).

DISCUSSION

Initially, we recommend a laboratory test to measure anti-neutrophil cytoplasmic antibodies (ANCA). 77 Kallenberg CGM, Brouwer E, Weening JJ, Cohen Tervaert JW. Anti-neutrophil cytoplasmic antibodies: current diagnostic and pathophysiological potential. Kidney Int. 1994;46(1):1-15. http://dx.doi.org/10.1038/ki.1994.239. PMid:7933826.
http://dx.doi.org/10.1038/ki.1994.239 ...

These antibodies are immunoglobulins against azurophil granules containing many different proteins, such as myeloperoxidase (MPO), elastase, proteinase 3 (PR3), and cathepsin G, among others. 77 Kallenberg CGM, Brouwer E, Weening JJ, Cohen Tervaert JW. Anti-neutrophil cytoplasmic antibodies: current diagnostic and pathophysiological potential. Kidney Int. 1994;46(1):1-15. http://dx.doi.org/10.1038/ki.1994.239. PMid:7933826.
http://dx.doi.org/10.1038/ki.1994.239 ...
,1515 Radu AS, Levi M. Anticorpos contra o citoplasma de neutrófilos. J Bras Pneumol. 2005;31(Suppl 1):s16-20. http://dx.doi.org/10.1590/S1806-37132005000700006.
http://dx.doi.org/10.1590/S1806-3713200...

Antibodies that target myeloperoxidase are called P-ANCA, since they usually present with a perinuclear staining pattern in indirect immunofluorescence. If the antibodies target Proteinase 3, they are known as C-ANCA, because they exhibit a central cytoplasmic staining pattern. 77 Kallenberg CGM, Brouwer E, Weening JJ, Cohen Tervaert JW. Anti-neutrophil cytoplasmic antibodies: current diagnostic and pathophysiological potential. Kidney Int. 1994;46(1):1-15. http://dx.doi.org/10.1038/ki.1994.239. PMid:7933826.
http://dx.doi.org/10.1038/ki.1994.239 ...
,1515 Radu AS, Levi M. Anticorpos contra o citoplasma de neutrófilos. J Bras Pneumol. 2005;31(Suppl 1):s16-20. http://dx.doi.org/10.1590/S1806-37132005000700006.
http://dx.doi.org/10.1590/S1806-3713200...

Radice et al. strongly confirm the accuracy of C-ANCA (PR3-ANCA) and P-ANCA (MPO-ANCA) for diagnostic investigation of vasculitis. 1616 Radice A, Bianchi L, Sinico RA. Anti-neutrophil cytoplasmic autoantibodies: methodological aspects and clinical significance in systemic vasculitis. Autoimmun Rev. 2013;12(4):487-95. http://dx.doi.org/10.1016/j.autrev.2012.08.008. PMid:22921790.
http://dx.doi.org/10.1016/j.autrev.2012...
,1717 Lionaki S, Blyth ER, Hogan SL, et al. Classification of antineutrophil cytoplasmic autoantibody vasculitides: the role of antineutrophil cytoplasmic autoantibody specificity for myeloperoxidase or proteinase 3 in disease recognition and prognosis. Arthritis Rheum. 2012;64(10):3452-62. http://dx.doi.org/10.1002/art.34562. PMid:23023777.
http://dx.doi.org/10.1002/art.34562 ...

Wegener's granulomatosis or granulomatosis with poliangiitis (WG/GPA) is characterized by granulomatous necrotizing vasculitis and lung-kidney syndrome. A positive C-ANCA result has sensitivity and specificity exceeding 90% for active WG/GPA disease. 1818 Homer RJ. Antineutrophil cytoplasmic antibodies as markers for systemic autoimmune disease. Clin Chest Med. 1998;19(4):627-39, viii. http://dx.doi.org/10.1016/S0272-5231(05)70107-6. PMid:9917957.
http://dx.doi.org/10.1016/S0272-5231(05...

Primary vasculitis with lung-kidney syndrome may occur with negative C-ANCA and positive P-ANCA. This form is classified as microscopic polyangiitis. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,1717 Lionaki S, Blyth ER, Hogan SL, et al. Classification of antineutrophil cytoplasmic autoantibody vasculitides: the role of antineutrophil cytoplasmic autoantibody specificity for myeloperoxidase or proteinase 3 in disease recognition and prognosis. Arthritis Rheum. 2012;64(10):3452-62. http://dx.doi.org/10.1002/art.34562. PMid:23023777.
http://dx.doi.org/10.1002/art.34562 ...
Previously established algorithms using P-ANCA for microscopic polyangiitis (MPA) diagnosis have high accuracy.

Lionaki et al. 1717 Lionaki S, Blyth ER, Hogan SL, et al. Classification of antineutrophil cytoplasmic autoantibody vasculitides: the role of antineutrophil cytoplasmic autoantibody specificity for myeloperoxidase or proteinase 3 in disease recognition and prognosis. Arthritis Rheum. 2012;64(10):3452-62. http://dx.doi.org/10.1002/art.34562. PMid:23023777.
http://dx.doi.org/10.1002/art.34562 ...
conducted a 22-year cohort study with 502 patients in which 81% of patients with microscopic polyangiitis were positive for P-ANCA.

Primary vasculitides of small vessels without lung-kidney syndrome can also occur with negative C-ANCA and positive P-ANCA. This form is known as eosinophilic granulomatosis with polyangiitis or Churg-Strauss syndrome (EGPA/CSS). These patients may have asthma, eosinophilia, and peripheral neuropathy. 33 Alberti-Violetti S, Berti E, Marzano AV. Cutaneous and systemic vasculitides in dermatology: a histological perspective. G Ital Dermatol Venereol. 2018;153(2):185-93. PMid:29368866. ,66 Jennette JC, Falk RJ, Andrassy K, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 1994;37(2):187-92. http://dx.doi.org/10.1002/art.1780370206. PMid:8129773.
http://dx.doi.org/10.1002/art.178037020...

When the results of P-ANCA and C-ANCA are negative in diagnostic investigation of primary vasculitides of small vessels, a second stage of laboratory tests is needed, assaying immunoglobulin A ( Figure 1 ).

In a retrospective study with 417 patients with IgA vasculitis or Henoch-Schönlein purpura (HSP) treated at a single center over 37 years, Calvo-Rio et al. did not detect positive ANCA in any patients. 1919 Calvo-Rio V, Loricera J, Mata C, et al. Henoch-Schonlein purpura in northern Spain: clinical spectrum of the disease in 417 patients from a single center. Medicine. 2014;93(2):106-13. http://dx.doi.org/10.1097/MD.0000000000000019. PMid:24646467.
http://dx.doi.org/10.1097/MD.0000000000...

Patients with HSP may have anaphylactoid purpura, abdominal pains, and peripheral neuropathy. 2020 Brogan P, Eleftheriou D. Vasculitis update: pathogenesis and biomarkers. Pediatr Nephrol. 2018;33(2):187-98. http://dx.doi.org/10.1007/s00467-017-3597-4. PMid:28785984.
http://dx.doi.org/10.1007/s00467-017-35...

When the results of P-ANCA, C-ANCA and IgA are all negative, it is necessary to conduct a third stage of laboratory tests, for cryoglobulin I, II and III ( Figure 1 ).

Cryoglobulins are insoluble immunoglobulins at temperatures below 37 degrees Celsius. These deposits generate inflammatory processes in innumerable tissues. 44 Ramos-Casals M, Stone JH, Cid MC, Bosch X. The cryoglobulinaemias. Lancet. 2012;379(9813):348-60. http://dx.doi.org/10.1016/S0140-6736(11)60242-0. PMid:21868085.
http://dx.doi.org/10.1016/S0140-6736(11...
,2121 Souza AW. Autoantibodies in systemic vasculitis. Front Immunol. 2015;6:184. PMid:25954277.

Systemic cryoglobulinaemic vasculitis (SCV) type I is characterized by monoclonal IgM and is associated with lymphoproliferative diseases, such as myeloma and lymphoma. 2222 Cacoub P, Comarmond C, Domont F, Savey L, Saadoun D. Cryoglobulinemia Vasculitis. Am J Med. 2015;128(9):950-5. http://dx.doi.org/10.1016/j.amjmed.2015.02.017. PMid:25837517.
http://dx.doi.org/10.1016/j.amjmed.2015...
Type II SCV is characterized by monoclonal and polyclonal IgM and IgG and is linked with infectious diseases, such as hepatitis C. 2222 Cacoub P, Comarmond C, Domont F, Savey L, Saadoun D. Cryoglobulinemia Vasculitis. Am J Med. 2015;128(9):950-5. http://dx.doi.org/10.1016/j.amjmed.2015.02.017. PMid:25837517.
http://dx.doi.org/10.1016/j.amjmed.2015...
,2323 Ragab G, Hussein MA. Vasculitic syndromes in hepatitis C virus: a review. J Adv Res. 2017;8(2):99-111. http://dx.doi.org/10.1016/j.jare.2016.11.002. PMid:28149646.
http://dx.doi.org/10.1016/j.jare.2016.1...
Type III SCV is characterized by polyclonal IgM and IgG and is associated with inflammatory diseases such as ulcerative colitis and Crohn’s disease. 33 Alberti-Violetti S, Berti E, Marzano AV. Cutaneous and systemic vasculitides in dermatology: a histological perspective. G Ital Dermatol Venereol. 2018;153(2):185-93. PMid:29368866. ,2424 Simonetti O, Postacchini V, Offidani A. Cutaneous vasculitis and inflammatory bowel diseases. G Ital Dermatol Venereol. 2015;150(2):233-6. PMid:25830412.

When the results of P-ANCA, C-ANCA, IgA and cryoglobulins are negative in diagnostic investigation of primary vasculitis of small vessels, a fourth and final step is needed.

The final phase is to investigate the possibility of leukocytoclastic vasculitis and Behçet's disease. These cutaneous vasculitides (CV) also affect small vessels ( Figure 1 ). 2525 Arora A, Wetter DA, Gonzalez-Santiago TM, Davis MD, Lohse CM. Incidence of leukocytoclastic vasculitis, 1996 to 2010: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2014;89(11):1515-24. http://dx.doi.org/10.1016/j.mayocp.2014.04.015. PMid:24981218.
http://dx.doi.org/10.1016/j.mayocp.2014...

Leukocytoclastic vasculitis or hypersensitivity vasculitis, is a vasculitis of small vessels that mainly affects venules through deposition of immune complexes and has a pathognomonic microscopic profile. Histopathology shows visible karyorrhexis with inflammatory infiltrate, fibrinoid necrosis, and neutrophil nucleus fragmentation in the vascular wall. 33 Alberti-Violetti S, Berti E, Marzano AV. Cutaneous and systemic vasculitides in dermatology: a histological perspective. G Ital Dermatol Venereol. 2018;153(2):185-93. PMid:29368866. ,2626 Carlson JA. The histological assessment of cutaneous vasculitis. Histopathology. 2010;56(1):3-23. http://dx.doi.org/10.1111/j.1365-2559.2009.03443.x. PMid:20055902.
http://dx.doi.org/10.1111/j.1365-2559.2...
,2727 Loricera J, Calvo-Rio V, Mata C, et al. Urticarial vasculitis in northern Spain: clinical study of 21 cases. Medicine. 2014;93(1):53-60. http://dx.doi.org/10.1097/MD.0000000000000013. PMid:24378743.
http://dx.doi.org/10.1097/MD.0000000000...

Behçet's disease is a systemic vasculitis of both arteries and veins, described with recurrent genital and oral ulcers, uveitis, and ectropion. Inflammatory lesions in the central nervous system and large vessels are rarely found. 2828 Neves FS, Moraes JC, Gonçalves CR. Síndrome de Behçet: à procura de evidências. Rev Bras Reumatol. 2006;46(Suppl 1):21-9. http://dx.doi.org/10.1590/S0482-50042006000700005.
http://dx.doi.org/10.1590/S0482-5004200...
Its most common presentation affects mainly small vessels. 22 Jennette JC, Falk RJ, Bacon PA, et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1-11. http://dx.doi.org/10.1002/art.37715. PMid:23045170.
http://dx.doi.org/10.1002/art.37715 ...
,2828 Neves FS, Moraes JC, Gonçalves CR. Síndrome de Behçet: à procura de evidências. Rev Bras Reumatol. 2006;46(Suppl 1):21-9. http://dx.doi.org/10.1590/S0482-50042006000700005.
http://dx.doi.org/10.1590/S0482-5004200...

Diagnosis of cutaneous vasculitides is effective and accessible because of their unique clinical, epidemiological, and histopatological features. 2525 Arora A, Wetter DA, Gonzalez-Santiago TM, Davis MD, Lohse CM. Incidence of leukocytoclastic vasculitis, 1996 to 2010: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2014;89(11):1515-24. http://dx.doi.org/10.1016/j.mayocp.2014.04.015. PMid:24981218.
http://dx.doi.org/10.1016/j.mayocp.2014...

At most health services, the routine diagnostic algorithm of investigation for primary vasculitides is extremely complex, laborious, time-consuming and expensive.

The diagnostic sequence shown above is not intended to eliminate additional clinical, radiological, or laboratory workup, which may be essential in selected cases. However, arriving at a diagnosis in a labor-saving and affordable manner is imperative.

In conclusion, the algorithm presented in this article enables fast, simple, and cost-effective diagnosis of primary vasculitides using just clinical concepts and a few laboratory tests.

  • How to cite: Bezerra AS, Polimanti AC, Fürst RVC, Corrêa JA. Algorithm for diagnosis of primary vasculitides. J Vasc Bras. 2019;18: e20180092. https://doi.org/10.1590/1677-5449.009218
  • Financial support: None.
  • The study was carried out at Disciplina de Angiologia e Cirurgia Vascular, Faculdade de Medicina do ABC, São Paulo, SP, Brazil.

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Publication Dates

  • Publication in this collection
    28 Mar 2019
  • Date of issue
    2019

History

  • Received
    28 Sept 2018
  • Accepted
    06 Dec 2018
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