Serological Studies Research Articles

Cat Scratch Disease of the Breast/Axilla: Recognition of a Rare Disease and Approaches for Differential Diagnosis.

Cat scratch disease rarely presents as a breast or axillary mass mimicking carcinoma both clinically and radiologically. Diagnosing breast/axillary cat scratch disease is challenging due to its rarity and nonspecific findings. Here, we reported 2 patients with breast cat scratch disease and reviewed 14 patients with cat scratch disease involving breast/axilla from the past 30 years. It mainly affects women (median age: 48), consistently presenting as axillary lymphadenopathy, and demonstrates ipsilateral breast mass in half of patients (50%, 8/16). The breast mass was most commonly located in the upper outer quadrant (88%, 7/8), indicating the possibility of disease extension from axillary adenopathy. Around half of patients (56%, 9/16) reported cat exposure. Histologically, most patients (93%, 14/15) presented as necrotizing granulomas, with characteristic stellate-shaped necrosis in 5 patients. Although pathologic differential diagnoses between cat scratch disease and cancer are straightforward, distinguishing cat scratch disease from other granulomatous mastitis poses diagnostic challenges. Silver stains should be included in the diagnostic workup panel when highly suspecting cat scratch disease clinically. However, they were only able to highlight the causative microorganism in 54% (7/18) patients, and the gram stain was negative in all 12 tested patients. In contrast, polymerase chain reaction (PCR) for the causative microorganism was consistently positive in all 3 tested patients, while serologic test confirmed diagnosis in 85% (11/13) patients; 1 patient with negative serology showed a positive PCR result. Therefore, upfront PCR tests with or without serologic study should be considered to confirm the diagnosis of cat scratch disease in a timely manner.

Hybrid glycophorin GP (A-B) and anti-Ena antibody in a multiparous woman

Abstract The MNS system is a large, complex group of antigens, with 50 antigens at present. The major antigens of the system are carried on glycophorins A and B, which are important red cell sialoglycoproteins. Altered expression of MNS antigens is possible in cases where there is a formation of hybrid glycophorins. Some of these patients may make clinically significant antibodies which can be associated with hemolytic transfusion reactions (HTR) or hemolytic disease of the fetus and the newborn. This is a report of one such case with both these phenomena, in a multiparous woman. Incompatible cross-matches at the referral center caused the samples to be sent to this immunohematological laboratory where the serological profile was detailed. On sending the samples to a third blood group reference laboratory, gene sequencing was done and the antibody was identified. At this immunohematological laboratory, the phenotype was determined as M-N+. The patient’s sera showed panreactivity with all panel cells (3-cell and 11-cell). At blood group reference laboratory, the findings were as follows- GYP (A-B) hybrid gene consistent with hemi/homozygosity for GYP*JL was confirmed and the panreactive antibody was identified as anti - Ena. Rare, atypical phenotypes in the MNS system can result from mutations affecting the sialoglycoproteins the antigens are carried on. The subset of antigens expressed in individual phenotypes varies and these patients can develop antibodies against the antigens they lack. When they present with immunohematological challenges such as panreactivity and incompatibility, a combination of serology, molecular technologies, and family studies help solve the problem. Alternatives to transfusion are also useful options in managing such cases.

One novel single nucleotide polymorphism c.424A>G on A1.02 allele in ABO glycosyltransferases leads to Aweak phenotype

BackgroundThe dysfunction of the ABO glycosyltransferase (GT) enzyme, which is caused by mutations in the ABO gene, can lead to weak ABO phenotypes. In this study, we have discovered a novel weak ABO subgroup allele and investigated the underlying mechanism to causing its Aweak phenotype. Materials and methodsThe ABO phenotyping and genotyping were performed by serological studies and direct DNA sequencing of ABO gene. The role of the novel single nucleotide polymorphism (SNP) was evaluated by 3D model, predicting protein structure changes, and in vitro expression assay. The total glycosyltransferase transfer capacity in supernatant of transfected cells was examined. ResultsThe results of serological showed the subject was Aweak phenotype. A novel SNP c.424A > G (p. M142V) based on ABO∗A1.02 was identified, and the genotype of the subject was AW-var/O.01 according to the gene analysis. In silico analysis showed that the SNP c.424A > G on the A allele may change the local conformation by damaging the hydrogen bonds and reduce the stability of GT. In vitro expression study showed that SNP p.M142V impaired H to A antigen conversion, although it did not affect the generation of A glycosyltransferase (GTA). ConclusionOne novel AW allele was identified and the SNP c.424A > G (p.M142V) can cause the Aweak phenotype through damaging the hydrogen bonds and reducing stability of the GTA.

AutoTransOP: translating omics signatures without orthologue requirements using deep learning

The development of therapeutics and vaccines for human diseases requires a systematic understanding of human biology. Although animal and in vitro culture models can elucidate some disease mechanisms, they typically fail to adequately recapitulate human biology as evidenced by the predominant likelihood of clinical trial failure. To address this problem, we developed AutoTransOP, a neural network autoencoder framework, to map omics profiles from designated species or cellular contexts into a global latent space, from which germane information for different contexts can be identified without the typically imposed requirement of matched orthologues. This approach was found in general to perform at least as well as current alternative methods in identifying animal/culture-specific molecular features predictive of other contexts—most importantly without requiring homology matching. For an especially challenging test case, we successfully applied our framework to a set of inter-species vaccine serology studies, where 1-to-1 mapping between human and non-human primate features does not exist.

Neutralizing and enhancing monoclonal antibodies in SARS-CoV-2 convalescent patients: lessons from early variant infection and impact on shaping emerging variants

ABSTRACT Serological studies of COVID-19 convalescent patients have identified polyclonal lineage-specific and cross-reactive antibodies (Abs), with varying effector functions against virus variants. Individual specificities of anti-SARS-CoV-2 Abs and their impact on infectivity by other variants have been little investigated to date. Here, we dissected at a monoclonal level neutralizing and enhancing Abs elicited by early variants and how they affect infectivity of emerging variants. B cells from 13 convalescent patients originally infected by D614G or Alpha variants were immortalized to isolate 445 naturally-produced anti-SARS-CoV-2 Abs. Monoclonal antibodies (mAbs) were tested for their abilities to impact the cytopathic effect of D614G, Delta, and Omicron (BA.1) variants. Ninety-eight exhibited robust neutralization against at least one of the three variant types, while 309 showed minimal or no impact on infectivity. Thirty-eight mAbs enhanced infectivity of SARS-CoV-2. Infection with D614G/Alpha variants generated variant-specific (65 neutralizing Abs, 35 enhancing Abs) and cross-reactive (18 neutralizing Abs, 3 enhancing Abs) mAbs. Interestingly, among the neutralizing mAbs with cross-reactivity restricted to two of the three variants tested, none demonstrated specific neutralization of the Delta and Omicron variants. In contrast, cross-reactive mAbs enhancing infectivity (n = 3) were found exclusively specific to Delta and Omicron variants. Notably, two mAbs that amplified in vitro the cytopathic effect of the Delta variant also exhibited neutralization against Omicron. These findings shed light on functional diversity of cross-reactive Abs generated during SARS-CoV-2 infection and illustrate how the balance between neutralizing and enhancing Abs facilitate variant emergence.

Seroprevalence of tick-borne encephalitis virus and vaccination coverage of tick-borne encephalitis, Sweden, 2018 to 2019.

BackgroundIn Sweden, information on seroprevalence of tick-borne encephalitis virus (TBEV) in the population, including vaccination coverage and infection, is scattered. This is largely due to the absence of a national tick-borne encephalitis (TBE) vaccination registry, scarcity of previous serological studies and use of serological methods not distinguishing between antibodies induced by vaccination and infection. Furthermore, the number of notified TBE cases in Sweden has continued to increase in recent years despite increased vaccination.AimThe aim was to estimate the TBEV seroprevalence in Sweden.MethodsIn 2018 and 2019, 2,700 serum samples from blood donors in nine Swedish regions were analysed using a serological method that can distinguish antibodies induced by vaccination from antibodies elicited by infection. The regions were chosen to reflect differences in notified TBE incidence.ResultsThe overall seroprevalence varied from 9.7% (95% confidence interval (CI): 6.6-13.6%) to 64.0% (95% CI: 58.3-69.4%) between regions. The proportion of vaccinated individuals ranged from 8.7% (95% CI: 5.8-12.6) to 57.0% (95% CI: 51.2-62.6) and of infected from 1.0% (95% CI: 0.2-3.0) to 7.0% (95% CI: 4.5-10.7). Thus, more than 160,000 and 1,600,000 individuals could have been infected by TBEV and vaccinated against TBE, respectively. The mean manifestation index was 3.1%.ConclusionA difference was observed between low- and high-incidence TBE regions, on the overall TBEV seroprevalence and when separated into vaccinated and infected individuals. The estimated incidence and manifestation index argue that a large proportion of TBEV infections are not diagnosed.

Rheumatoid Arthritis and Pericardial Effusion - A Unique Major Manifestation.

Pericardial effusion is common in the setting of rheumatoid arthritis (RA); however, it is rarely its first manifestation. An 82-year-old male presented with abdominal pain, vomiting and fever. Blood analysis revealed elevated systemic inflammatory markers, and an abdominal computed tomography scan revealed non-specific alveolar condensation of the right pulmonary base and pericardial effusion subsequently quantified as medium size by transthoracic echocardiography. A large aetiological panel was requested, with the autoimmunity study revealing high levels of rheumatoid factor (RF) and anti-citrullinated cyclic peptide (anti-CCP) antibodies. Since the patient did not present articular involvement, the initial hypothesis was pericardial effusion due to pneumonia and no specific treatment for RA was started. At follow-up, the pericardial effusion recurred and a pericardiocentesis was performed. The pericardial fluid analysis was sterile, and no malignant cells were identified. A new serological study confirmed high levels of RF and anti-CCP antibodies, and immunomodulatory treatment was initiated. After one year, the pericardial effusion recurred due to non-compliance with immunomodulatory therapy. A surgical pleuro-pericardial window was performed, and the cytological study of the pericardial patch revealed submesothelial thickening and foci of perivascular lymphocytic infiltrate. The patient remained asymptomatic. After exclusion of a large spectrum of infectious and non-infectious causes and the relapse after suspension of immunomodulatory treatment, the most probable aetiology for the pericardial effusion remains RA. Pericardial syndromes can be the first manifestation of AR even in the absence of articular symptoms and this disease must be considered in the aetiological investigation. The occurrence of pericardial effusion in the setting of rheumatoid arthritis (RA) is a usual finding but this form of extra-articular manifestation is possibly the first and only presentation of the disease.In the case of recurrent pericardial effusion, the diagnosis of RA must be considered in the aetiological investigation even in the absence of more common manifestations of the disease.

SPECTRUM OF HEMATOLOGICAL DISORDERS IN BONE MARROW EXAMINATION

Objective: To study the bone marrow aspiration (BMA) trends and to observe and analyze the various patterns of hematological disorders in bone marrow examinations of patients attending a tertiary care teaching hospital. Methods: A 2-year study was done retrospectively in the department of pathology at the tertiary care teaching hospital. Relevant demographics, clinical details, intraprocedural details, and results were obtained through records and case files. Results: A total of 48 cases were studied. The most common diagnoses recorded were erythroid hyperplasia, nutritional anemia, megaloblastic anemia, acute leukemias, etc. Conclusion: Bone marrow cytology is a highly informative and diagnostic test procedure performed in evaluating blood and blood-related diseases. Some hematological conditions can be diagnosed with serological studies, and the need for an invasive test like BMA can be avoided.

Epilepsy as Central Nervous System Involvement in Patient with ANCA-Associated Vasculitis: A Case Report

Central nervous system (CNS) involvement by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare presentation. The affected nerve structure determines the symptoms of AAV. Presentation as seizures can make early diagnosis difficult by necessitating the ruling out of other etiologies, which increases mortality in these patients. Serological and imaging studies facilitate the identification of AAV and initiation of timely treatment focused on remission of the autoimmune pathology. We present the case of a young female patient who, after diagnosis with AAV by renal biopsy, presented with several epileptic seizures. With angioresonance, we evidenced vascular involvement and began remission treatment with an adequate resolution of the seizures.

Assessment of registered and hidden epidemic process of tick-borne encephalitis in the Republic of Karelia

Introduction. The incidence of tick-borne encephalitis in the Russia remains relevant. The assessment of the epidemic process in the Republic of Karelia is important not only in terms of understanding its general patterns, but in connection with the growth of tourist attendance in the region.
 Aims: To assess the current epidemic situation of tick-borne encephalitis in the Republic of Karelia, and to compare the characteristics of registered and hidden epidemic processes.
 Materials and methods. The risk of infection and incidence were estimated based on the analysis of the registered cases of seeking medical help in connection with tick bites, the results of a study of tick-borne encephalitis virus (TBEV) infection rate in ticks, and the epidemiological investigation of cases of tick-borne encephalitis in 1992–2022. Clinical, gender and age structure, territorial distribution of patients and victims of the tick bites were compared with the results of serological studies of 2379 blood samples of the adult population, conducted in 2011–2022.
 Results. Infection rates of ticks removed from humans ranged from 23.6–27.0% in 2002–2005 to 1.0% in 2022. In 2004, the TBEV antigen was detected in mosquitoes. The territory of risk is the southern part of Republic. However, the increase in number of cases of seeking medical help was observed in the northern part of Republic. The incidence rates exceeded the national average, especially in 2003–2004 (15.3–11.6 per 100 thousand). In 2021–2022, it decreased to 1.8–1.5 per 100,000. The dynamics of incidence had a high-degree correlation with the dynamics of seeking medical help and infection rates in ticks (R = 0.92 and 0.73). The reported incidence was lower than the estimated risk of infection. The meningeal forms of infection were most often diagnosed. The risk of the disease was higher in the elderly and in men, which was determined by the conditions of infection. Antibodies to TBEV were detected in 11.8 ± 0.7% of the examined persons.
 Conclusion. A steady decrease in rates of registered tick-borne encephalitis incidence has been revealed in the Republic of Karelia, mainly due to the action of biological and natural factors. The assessment of seroprevalence made it possible to reveal the hidden part of the epidemic process.

Detection of foot-and-mouth disease viruses from the A/AFRICA/G-I genotype in the Sultanate of Oman

Rapid identification and characterization of circulating foot-and-mouth disease virus (FMDV) strains is crucial for effective disease control. In Oman, a few serological and molecular studies have been conducted to identify the strains of FMDV responsible for the outbreaks that have been occurring within the country. In this study, 13 oral epithelial tissue samples from cattle were collected from suspected cases of FMD in Ash Sharqiyah North, Al Batinah North, Dhofar and Ad Dhakhyilia governorates of Oman between 2018 and 2021. FMDV RNA was detected in all samples by real-time RT-PCR and viruses were isolated after one- or two-blind passages in the porcine Instituto Biologico-Rim Suino-2 cell line. Antigen capture ELISA characterized all isolates as serotype A and VP1 phylogenetic analysis placed all sequences within a single clade of the G-I genotype within the A/AFRICA topotype. These sequences shared the closest nucleotide identities to viruses circulating in Bahrain in 2021 (93.5% to 99.5%) and Kenya in 2017 (93.4% to 99.1%). To the best of our knowledge, this is the first time that A/AFRICA/G-I viruses have been detected in Oman. Together with the closely related viruses detected recently in Bahrain, these findings reinforce the importance of deploying effective quarantine control measures to minimize the risks of transboundary transmission of FMD associated with the importation of cattle from East Africa.

Celiac disease presenting as hemorrhagic shock: a rare complication.

Celiac disease (CD) is a systemic autoimmune disorder triggered by ingested gluten in patients with genetic susceptibility, with rising incidence in adults. In this population, symptoms can be atypical. We report the case of a 71-year-old woman that presented with coagulopathy due to severe vitamin K deficiency and hemorrhagic shock, as well as cholestatic hepatitis and chronic diarrhea. Serological studies were negative for CD, but a biopsy demonstrated duodenal atrophy and HLA typing was positive for DQ2.5, pointing to this diagnosis. The patient responded favorably to a gluten free diet. This case highlights the challenge in diagnosing CD in elderly patients due to its unusual manifestations, which can range from mild and unspecific to potentially life-threatening. The exclusion of other causes of duodenal atrophy is key in establishing the diagnosis, especially in seronegative cases, permitting the establishment of an adequate therapy and follow-up strategy.

Эпидемиология инфекции Helicobacter pylori в Российской Федерации с 1990 по 2023 г.: систематический обзор

H. pylori affects more than half of the world's population and is associated with chronic gastritis, which can progress to serious complications such as peptic ulcer disease, gastric cancer, and MALT lymphoma. Epidemiological studies allow for the assessment of the level and changes in the prevalence of H. pylori infection. This paper addresses the results of H. pylori prevalence studies conducted in the Russian Federation. The high prevalence of H. pylori in adults and children in the 1990s and its significant reduction in recent years are reported. The prevalence of infection in adults is greater than in children in all time intervals studied, which is probably associated with poorer sociohygienic conditions in childhood in previous generations. The results of epidemiological studies on the prevalence of H. pylori are heterogeneous and depend on the time of the study, the region, and diagnostic method. The prevalence of H. pylori infection as determined by the 13C urea breath test has been found to be lower than that observed in serological studies. This discrepancy is attributed to the greater specificity of the breath test in detecting current infection KEYWORDS: Helicobacter pylori, epidemiological study, prevalence of H. pylori, Helicobacter infection, Russian Federation. FOR CITATION: Bordin D.S., Kuznetsova E.S., Stauver E.E., Nikol'skaya K.A., Chebotareva M.V., Voynovan I.N., Neyasova N.A. Epidemiology of Helicobacter pylori infection in the Russian Federation from 1990 to 2023: a systematic review. Russian Medical Inquiry. 2024;8(5):260–267 (in Russ.). DOI: 10.32364/2587-6821-2024-8-5-3.

Seroprevalence of anti-SARS-CoV-2 antibodies and risk of viral exposure among healthcare workers in the South Kivu province, eastern Democratic Republic of the Congo: a cross-sectional study

ObjectivesHealthcare workers (HCWs) are on the frontline of combating COVID-19, hence are at elevated risk of contracting an infection with SARS-CoV-2. The present study aims to measure the impact of...

A Serological Study on Hydatid Disease from a Tertiary Care Hospital in Southern India: A Retrospective Observational Study

Introduction: Echinococcus species are zoonotic parasites that cause hydatid disease, affecting humans and animals. The seroprevalence of hydatid disease reflects the level of exposure to this parasite and can be used as an indicator of the burden of the disease in a population. Aim: To determine the seroprevalence of hydatid disease. Materials and Methods: The study was a retrospective observational study conducted at JIPMER hospital, a tertiary care centre located in Puducherry, Southern India. In this study, hydatid serological data from January 2019 to December 2022 were collected in March 2023 and retrospectively analysed in April 2023. All the serum samples that tested positive for Enzyme Linked Immuno Sorbent Assay (ELISA) for echinococcosis during the period from January 2019 to December 2022 were included. The demographic details such as age, gender, place of residence, etc., of the patients whose samples were included were collected from their case records. These samples were then analysed using Microsoft Excel for proportions and percentages. Results: The study showed that the seroprevalence of hydatid disease was 70 (34%) out of 206 samples tested. The seroprevalence was higher in the older age group (>45 years), with 41 (58.6%) cases. It was observed that males and females were almost equally infected, with minor differences in the prevalence of 37 (52.9%) males and 33 (47.1%) females. Conclusion: As the prevalence of hydatid disease in Southern India was unknown, it was observed to be lower when compared to other states of India. This study has provided valuable information on the level of exposure of hydatid disease in the population and will help formulate disease control and prevention strategies.

Detection of antibodies against structural proteins of foot-and-mouth disease virus in bovines of western Uttar Pradesh, India.

Foot-and-mouth disease (FMD) is considered as one of the most important contagious viral diseases affecting cloven-footed animals. For effective control of FMD, immunization along with herd immunity is essential in the field conditions. To assure and track the coverage and effectiveness of the vaccination program, the serological studies are very much required after the vaccination program. The present study was aimed to investigate the prevalence of antibodies against structural proteins of FMD virus (FMDV) serotypes of O, A and Asia-1 in seven districts of western Uttar Pradesh, India, and assure the efficacy of vaccination under National Animal Disease Control Program. A total of 308 sera samples were collected from apparent healthy vaccinated cattle and buffaloes from seven districts including Amroha, Baghpat, Bareilly, Bulandsahar, Gautam Budh Nagar, Meerut and Muzaffarnagar of western Uttar Pradesh, India. Determination of antibodies against structural proteins of FMDV was carried out using solid-phase blocking enzyme-linked immunosorbent assay. The protective level of the FMDV serotypes O, A and Asia-1 included in the inactivated trivalent vaccine was 66.55, 48.05 and 47.08% in bovines, respectively. To provide the higher level of protection against the circulating FMDV, the present study recommended the thorough investigation of the immunogenic interaction between the vaccine strains and the field strains. Further investigations should also be conducted with larger sample size and across diverse geographical regions to gain a more comprehensive understanding of herd immunity.

Breaking Barriers: Current Advances and Future Directions in Mpox Therapy.

Mpox, a newly discovered zoonotic infection, can be transmitted from animal to human and between humans. Serological and genomic studies are used to identify the virus. Currently, there are no proven effective treatments for Mpox. Also, the safety and efficacy of intravenous vaccinia immune globulin, oral Tecovirimat (an inhibitor of intracellular viral release), and oral Brincidofovir (a DNA polymerase inhibitor) against the Mpox virus are uncertain, highlighting the need for more effective and safe treatments. As a result, drug repurposing has emerged as a promising strategy to identify previously licensed drugs that can be repurposed to treat Mpox. Various approaches have been employed to identify previously approved drugs that can target specific Mpox virus proteins, including thymidylate kinase, D9 decapping enzyme, E8 protein, Topoisomerase1, p37, envelope proteins (D13, A26, and H3), F13 protein, virus's main cysteine proteases, and DNA polymerase. In this summary, we provide an overview of potential drugs that could be used to treat Mpox and discuss the underlying biological processes of their actions.

Ocular myasthenia gravis

Myasthenia gravis is an autoimmune disease characterized by muscle weakness and pathological fatigue due to autoaggressive phenomena with the formation of antibodies directed against various structures of the neuromuscular synapse. In most patients, the disease begins with the involvement of extraocular muscles, presenting with symptoms such as intermittent ptosis of the upper eyelid and/or binocular diplopia. In 15% of cases, clinical manifestations are limited to impairment of the levator palpebrae superioris and extraocular muscles, characteristic of the ocular form of myasthenia gravis. Specialists often encounter challenges in diagnosing this form, as serological and electrophysiological studies may be uninformative, necessitating diagnosis based on patient history and clinical picture. This literature review outlines the key aspects of the pathogenesis, clinical manifestations, methods of diagnosis and treatment of ocular myasthenia gravis.

Detection of invasive Bartonella infections with next-generation sequencing of microbial cell-free DNA.

We report 9 patients with invasive Bartonella infections, including 5 with endocarditis, who were diagnosed with microbial cell-free DNA next-generation sequencing and Bartonella serology studies. Diagnosis with plasma mcfDNA NGS enabled a faster clinical and laboratory diagnosis in 8 patients. Prompt diagnosis impacted antibiotic management in all 9 patients.

Two Sides of the Same Coin: Eosinophilic and Herpetic Esophagitis in an Immunocompetent Young Adult.

Dear Editor, We report a case of a 30-year-old woman with an 8-year diagnosis of eosinophilic esophagitis (EoE) treated with swallowed fluticasone propionate throughout this period. She presented to the emergency room with a two-day history of severe odynophagia, aphagia, retrosternal pain, and fever. The patient was febrile and hemodynamically stable, with no visible oropharyngeal lesions. She presented with elevated C-reactive protein (37 mg/L). An esophagogastroduodenoscopy was performed, which revealed white plaque-like lesions with "volcano-like" shallow ulcerations with raised edges on the distal esophagus (Figure 1aandb). Multiple biopsies were taken from both the center and edges of the lesions. The patient was empirically started on intravenous fluconazole due to the suspicion of candida esophagitis. However, the patient's symptoms worsened over the next two days, and acyclovir at a dose of 5 mg/kg was started. The initial work-up showed a positive titer for Herpes Simplex Virus (HSV)-2 IgM (1.6 U/L) and a negative titer for IgG (2.24 U/L), as well as a negative serological study for HSV-1, cytomegalovirus, and human immunodeficiency virus (HIV). Histological examination revealed multinucleated giant cells with nuclear molding and chromatin margination and cells with "ground glass" nuclei, along with typical Cowdry type A intranuclear inclusion bodies and immunohistochemical staining for HSV type 2, confirmed the diagnosis of herpetic esophagitis (Figure 1candd). The patient experienced rapid improvement and was discharged on oral acyclovir therapy at 400 mg/day, completing a total of 14 days of treatment with a total resolution of symptoms.