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Topic:Immunology

The equine immune system is a complex network of cells, tissues, and organs that work collaboratively to defend against pathogens and maintain homeostasis. It consists of innate and adaptive components, each with distinct functions and mechanisms. The innate immune system provides the first line of defense through physical barriers, phagocytic cells, and the complement system. The adaptive immune system involves lymphocytes, such as B cells and T cells, which generate specific responses to antigens and provide immunological memory. Research in equine immunology explores the interactions between these components, the impact of genetic and environmental factors on immune function, and the development of vaccines and therapeutics. This page gathers peer-reviewed studies and scholarly articles focusing on the mechanisms, regulation, and clinical applications of the equine immune system in health and disease.
Lessons Learned from West Nile Virus Infection:Vaccinations in Equines and Their Implications for One Health Approaches.
Viruses    May 14, 2024   Volume 16, Issue 5 781 doi: 10.3390/v16050781
Naveed A, Eertink LG, Wang D, Li F.Humans and equines are two dead-end hosts of the mosquito-borne West Nile virus (WNV) with similar susceptibility and pathogenesis. Since the introduction of WNV vaccines into equine populations of the United States of America (USA) in late 2002, there have been only sporadic cases of WNV infection in equines. These cases are generally attributed to unvaccinated and under-vaccinated equines. In contrast, due to the lack of a human WNV vaccine, WNV cases in humans have remained steadily high. An average of 115 deaths have been reported per year in the USA since the first reported case in 1999. ...
Expression of IL-10 and TGF-β1 in horses experimentally infected with T. equi merozoites is associated with antibody production but not modulation of pro-inflammatory responses.
Frontiers in immunology    May 13, 2024   Volume 15 1370255 doi: 10.3389/fimmu.2024.1370255
Onzere CK, Bastos RG, Bishop RP, Suarez CE, Fry LM. () is an apicomplexan parasite that causes severe hemolytic anemia in equids. Presently, there is inadequate knowledge of the immune responses induced by in equid hosts impeding understanding of the host parasite relationship and development of potent vaccines for control of infections. The objective of this study was to evaluate the host-parasite dynamics between merozoites and infected horses by assessing cytokine expression during primary and secondary parasite exposure, and to determine whether the pattern of expression correlated with clinical indicators of disease. Our findings showe...
Immunology of Physical Exercise: Is Equus caballus an Appropriate Animal Model for Human Athletes?
International journal of molecular sciences    May 10, 2024   Volume 25, Issue 10 5210 doi: 10.3390/ijms25105210
Witkowska-Piłaszewicz O, Malin K, Dąbrowska I, Grzędzicka J, Ostaszewski P, Carter C.Domestic horses routinely participate in vigorous and various athletic activities. This enables the horse to serve as a model for studying athletic physiology and immunology in other species, including humans. For instance, as a model of physical efforts, such as endurance rides (long-distance running/aerobic exercise) and races (anaerobic exercise), the horse can be useful in evaluating post-exercise response. Currently, there has been significant interest in finding biomarkers, which characterize the advancement of training and adaptation to physical exercise in the horse. The parallels in c...
Identification of equine mares as reservoir hosts for pathogenic species of Leptospira.
Frontiers in veterinary science    May 9, 2024   Volume 11 1346713 doi: 10.3389/fvets.2024.1346713
Hamond C, Adam EN, Stone NE, LeCount K, Anderson T, Putz EJ, Camp P, Hicks J, Stuber T, van der Linden H, Bayles DO, Sahl JW, Schlater LK, Wagner DM....Equine leptospirosis can result in abortion, stillbirth, neonatal death, placentitis, and uveitis. Horses can also act as subclinical reservoir hosts of infection, which are characterized as asymptomatic carriers that persistently excrete leptospires and transmit disease. In this study, PCR and culture were used to assess urinary shedding of pathogenic Leptospira from 37 asymptomatic mares. Three asymptomatic mares, designated as H2, H8, and H9, were PCR-positive for lipL32, a gene specific for pathogenic species of Leptospira. One asymptomatic mare, H9, was culture-positive, and the recovered...
Monoclonal antibody development advances immunological research in horses.
Veterinary immunology and immunopathology    May 6, 2024   Volume 272 110771 doi: 10.1016/j.vetimm.2024.110771
Wagner B.Host immune analyses require specific reagents to identify cellular and soluble components of the immune system. These immune reagents are often species-specific. For horses, various immunological tools have been developed and tested by different initiatives during the past decades. This article summarizes the development of well characterized monoclonal antibodies (mAbs) for equine immune cells, immunoglobulin isotypes, cytokines, and chemokines.
Development of novel Streptococcus equi vaccines with an assessment of their immunizing potentials and protective efficacies.
BMC veterinary research    May 3, 2024   Volume 20, Issue 1 173 doi: 10.1186/s12917-024-04012-z
Soliman R, Yousef M, Gelil SA, Aboul-Ella H.Strangles is a highly contagious disease of the equine upper respiratory tract caused by Streptococcus equi subspecies. Streptococcus equi subsp. equi (S. equi) and Streptococcus equi subsp. zooepidemicus (S. zooepidemicus) was isolated, as local, hot, and field strains, from horses clinically suffering from respiratory distress. The isolated Streptococci were identified using bacteriological and molecular techniques. Four formulations of inactivated S. equi vaccines were developed and evaluated. The first formulation was prepared using the S. equi isolates, adjuvanted with MONTANIDE GEL adjuv...
Towards personalized medicine for the treatment of equine asthma.
Veterinary journal (London, England : 1997)    May 2, 2024   106125 doi: 10.1016/j.tvjl.2024.106125
Leduc L, Leclère M, Lavoie JP.Although horses with asthma share similar clinical signs, the heterogeneity of the disease in terms of severity, triggering factors, inflammatory profile, and pathological features has hindered our ability to define biologically distinct subgroups. The recognition of phenotypes and endotypes could enable the development of precision medicine, including personalized, targeted therapy, to benefit affected horses. While in its infancy in horses, this review outlines the phenotypes of equine asthma and discusses how knowledge gained from targeted therapy in human medicine can be applied to evaluat...
Vaccination and Control Methods of West Nile Virus Infection in Equids and Humans.
Vaccines    May 1, 2024   Volume 12, Issue 5 485 doi: 10.3390/vaccines12050485
Cendejas PM, Goodman AG.West Nile virus (WNV) is capable of causing severe neurologic disease in both humans and equines, making it a disease of importance in both human medicine and veterinary medicine. No targeted treatments exist for WNV infection in either humans or equines. Infection is treated symptomatically through management of symptoms like fever and seizures. As treatment for WNV is purely supportive, the response to WNV has focused primarily on methods of disease prevention. To this end, research efforts have yielded several effective vaccines for equine use as well as numerous conventional mosquito contr...
Effect of hospitalization on equine local intestinal immunoglobulin A (IgA) concentration measured in feces.
Journal of equine veterinary science    April 30, 2024   Volume 137 105078 doi: 10.1016/j.jevs.2024.105078
May A, Gerhards H, Wollanke B.During hospitalization horses may develop gastrointestinal conditions triggered by a stress-associated weak local immune system. The prospective, clinical trial was conducted to find out whether fecal immunoglobulin A (IgA) concentrations could be determined in hospitalized horses and how they changed during hospitalization and in response to various stressors. Samples were obtained from 110 horses and a control group (n = 14). At arrival in the hospital, horses were categorized into pain grades (1-5), and elective versus strenuous surgery (> 2 hours, traumatic and emergency procedures). Feces...
Neonatal and maternal upregulation of antileukoproteinase in horses.
Frontiers in immunology    April 26, 2024   Volume 15 1395030 doi: 10.3389/fimmu.2024.1395030
Holmes CM, Babasyan S, Wagner B.The end of gestation, ensuing parturition, and the neonatal period represent highly dynamic phases for immunological changes in both mother and offspring. The regulation of innate immune cells at the maternal-fetal interface during late term pregnancy, after birth, and during microbial colonization of the neonatal gut and other mucosal surfaces, is crucial for controlling inflammation and maintaining homeostasis. Innate immune cells and mucosal epithelial cells express antileukoproteinase (SLPI), which has anti-inflammatory and anti-protease activity that can regulate cellular activation. Unas...
Tumor necrosis factor-α is transferred to equine neonates via colostrum but is not associated with their health status.
Research in veterinary science    April 23, 2024   Volume 173 105273 doi: 10.1016/j.rvsc.2024.105273
Vaske A, Gautier C, Winter J, Aurich C.We followed the hypothesis that equine neonates with reduced transfer of tumor necrosis factor-α (TNFα) are at increased risk of neonatal infection. We investigated TNFα concentrations in colostrum of healthy mares and blood of their neonates in a non-hospitalized population of Warmblood mares where delivery, neonatal adaptation and health was closely monitored by veterinarians. Concentration of TNFα and IgG was determined in colostrum respective milk and in neonatal blood collected immediately after delivery and 18 h thereafter in 97 foals that were assigned to groups failure of passive ...
Immunogenic profile of a plant-produced nonavalent African horse sickness viral protein 2 (VP2) vaccine in IFNAR-/- mice.
PloS one    April 16, 2024   Volume 19, Issue 4 e0301340 doi: 10.1371/journal.pone.0301340
O'Kennedy MM, Roth R, Ebersohn K, du Plessis LH, Mamputha S, Rutkowska DA, du Preez I, Verschoor JA, Lemmer Y.A safe, highly immunogenic multivalent vaccine to protect against all nine serotypes of African horse sickness virus (AHSV), will revolutionise the AHS vaccine industry in endemic countries and beyond. Plant-produced AHS virus-like particles (VLPs) and soluble viral protein 2 (VP2) vaccine candidates were developed that have the potential to protect against all nine serotypes but can equally well be formulated as mono- and bi-valent formulations for localised outbreaks of specific serotypes. In the first interferon α/β receptor knock-out (IFNAR-/-) mice trial conducted, a nine-serotype (nona...
Genomic characterization of equine influenza A subtype H3N8 viruses by long read sequencing and functional analyses of the PB1-F2 virulence factor of A/equine/Paris/1/2018.
Veterinary research    March 22, 2024   Volume 55, Issue 1 36 doi: 10.1186/s13567-024-01289-8
Kleij L, Bruder E, Raoux-Barbot D, Lejal N, Nevers Q, Deloizy C, Da Costa B, Legrand L, Barrey E, Chenal A, Pronost S, Delmas B, Dhorne-Pollet S.Equine influenza virus (EIV) remains a threat to horses, despite the availability of vaccines. Strategies to monitor the virus and prevent potential vaccine failure revolve around serological assays, RT-qPCR amplification, and sequencing the viral hemagglutinin (HA) and neuraminidase (NA) genes. These approaches overlook the contribution of other viral proteins in driving virulence. This study assesses the potential of long-read nanopore sequencing for fast and precise sequencing of circulating equine influenza viruses. Therefore, two French Florida Clade 1 strains, including the one circulati...
Analysis of Trypanosoma equiperdum Recombinant Proteins for the Serological Diagnosis of Dourine.
Veterinary sciences    March 13, 2024   Volume 11, Issue 3 127 doi: 10.3390/vetsci11030127
Luciani M, Armillotta G, Di Febo T, Krasteva I, Ulisse S, Di Pancrazio C, Laguardia C, Perletta F, Serroni A, Maggetti M, Testa L, Sacchini F....The significance of as the causative agent of dourine cannot be understated, especially given its high mortality rate among equids. International movement of equids should be subject to thorough health checks and screenings to ensure that animals are not infected with . This involves the implementation of quarantine protocols, testing procedures, and the issuance of health certificates to certify the health status of the animals. Three proteins, the peptidyl-prolyl cis-trans isomerase (A0A1G4I8N3), the GrpE protein homolog (A0A1G4I464) and the transport protein particle (TRAPP) component, put...
Modulation of Equid Herpesvirus-1 Replication Dynamics In Vitro Using CRISPR/Cas9-Assisted Genome Editing.
Viruses    March 6, 2024   Volume 16, Issue 3 409 doi: 10.3390/v16030409
Hassanien RT, Thieulent CJ, Carossino M, Li G, Balasuriya UBR.(1) Background: equid alphaherpesvirus-1 (EHV-1) is a highly contagious viral pathogen prevalent in most horse populations worldwide. Genome-editing technologies such as CRISPR/Cas9 have become powerful tools for precise RNA-guided genome modifications; (2) Methods: we designed single guide RNAs (sgRNA) to target three essential (ORF30, ORF31, and ORF7) and one non-essential (ORF74) EHV-1 genes and determine their effect on viral replication dynamics ; (3) Results: we demonstrated that sgRNAs targeting essential lytic genes reduced EHV-1 replication, whereas those targeting ORF74 had a negligi...
Equine enteroid-derived monolayers recapitulate key features of parasitic intestinal nematode infection.
Veterinary research    February 27, 2024   Volume 55, Issue 1 25 doi: 10.1186/s13567-024-01266-1
Hellman S, Martin F, Tydén E, Sellin ME, Norman A, Hjertner B, Svedberg P, Fossum C.Stem cell-derived organoid cultures have emerged as attractive experimental models for infection biology research regarding various types of gastro-intestinal pathogens and host species. However, the large size of infectious nematode larvae and the closed structure of 3-dimensional organoids often hinder studies of the natural route of infection. To enable easy administration to the apical surface of the epithelium, organoids from the equine small intestine, i.e. enteroids, were used in the present study to establish epithelial monolayer cultures. These monolayers were functionally tested by s...
Pharmacologic interventions for the treatment of equine herpesvirus-1 in domesticated horses: A systematic review.
Journal of veterinary internal medicine    February 21, 2024   Volume 38, Issue 3 1892-1905 doi: 10.1111/jvim.17016
Goehring L, Dorman DC, Osterrieder K, Burgess BA, Dougherty K, Gross P, Neinast C, Pusterla N, Soboll-Hussey G, Lunn DP.Equine herpes virus type 1 (EHV-1) infection in horses is associated with upper respiratory disease, neurological disease, abortions, and neonatal death. Objective: Does pharmacological therapy decrease either the incidence or severity of disease or infection caused by EHV-1 in domesticated horses? Methods: A systematic review was preformed searching AGRICOLA, CAB Abstracts, Cochrane, PubMed, Web of Science, and WHO Global Health Index Medicus Regional Databases to identify articles published before February 15, 2021. Selection criteria were original research reports published in peer reviewed...
Diversity of major histocompatibility complex (MHC) and natural killer cell receptor (NKR) genes and their interactions in domestic horses.
HLA    February 15, 2024   Volume 103, Issue 2 e15387 doi: 10.1111/tan.15387
Bubenikova J, Plasil M, Futas J, Stejskalova K, Klumplerova M, Oppelt J, Suchentrunk F, Burger PA, Horin P.The immunogenome is the part of the genome that underlies immune mechanisms and evolves under various selective pressures. Two complex regions of the immunogenome, major histocompatibility complex (MHC) and natural killer cell receptor (NKR) genes, play an important role in the response to selective pressures of pathogens. Their importance is expressed by their genetic polymorphism at the molecular level, and their diversity associated with different types of diseases at the population level. Findings of associations between specific combinations of MHC/NKR haplotypes with different diseases i...
Evaluation of stability and safety of equine mesenchymal stem cells derived from amniotic fluid for clinical application.
Frontiers in veterinary science    February 14, 2024   Volume 11 1330009 doi: 10.3389/fvets.2024.1330009
Kim EY, Lee EJ, Kim RE, Kil TY, Kim MK.Amniotic fluid mesenchymal stem cells (AF-MSCs), which can be obtained from fetal tissue, reportedly have self-renewal capacity and multi-lineage differentiation potential. The aim of this study was to identify the biological characteristics of AF-MSCs and evaluate their stability and safety in long-term culture. To confirm the biological characteristics of AF-MSCs, morphology, proliferation capacity, karyotype, differentiation capacity, gene expression level, and immunophenotype were analyzed after isolating AF-MSCs from equine amniotic fluid. AF-MSCs were differentiated into adipocytes, chon...
Equine common variable immunodeficiency: lessons from 100 clinical cases.
Equine veterinary education    January 31, 2024   Volume 36, Issue 10 543-554 doi: 10.1111/eve.13948
Julia M, Felippe B.The clinical manifestation of recurrent fevers and infections alerts the clinician to the possibility of an underlying immunodeficiency. Common variable immunodeficiency (CVID) in the horse is a rare late-onset, non-familial immunologic disorder of B cell depletion and/or dysfunction with resultant inadequate antibody production. The most common clinical presentations in horses with CVID are recurrent upper and/or lower respiratory infections, meningitis and/or ataxia, cholangiohepatitis, infectious colitis, infectious dermatitis, and severe gastrointestinal parasitism. Immune-mediated and lym...
Expression of recombinant Florida clade 2 hemagglutinin in baculovirus expression system: A step for subunit vaccine development against H3N8 equine influenza virus.
Open veterinary journal    January 31, 2024   Volume 14, Issue 1 350-359 doi: 10.5455/OVJ.2024.v14.i1.32
Atwa AS, Gomaa L, Elmenofy W, Amer HM, Ahmed BM.Equine influenza (EI) is a transmissible viral respiratory sickness of the family. Two viruses, H7N7 and H3N8 caused EI; however, H7N7 has not been detected for decades. H3N8 has circulated and bifurcated into Eurasian and American lineages. The latter subsequently diversified into Kentucky, South America, and Florida sub-lineages. Florida clade 1 (FC1) and Florida clade 2 (FC2) strains are the only circulating EI viruses (EIVs) in the meantime. Immunization is considered the major means for the prevention and control of EI infection. Using disparate technologies and platforms, several vaccin...
Standardized guidelines for Africanized honeybee venom production needed for development of new apilic antivenom.
Journal of toxicology and environmental health. Part B, Critical reviews    January 26, 2024   Volume 27, Issue 2 73-90 doi: 10.1080/10937404.2023.2300786
Oliveira Orsi R, Zaluski R, de Barros LC, Barraviera B, Pimenta DC, Ferreira Junior RS.Africanized bees have spread across the Americas since 1956 and consequently resulted in human and animal deaths attributed to massive attacks related to exposure from Argentina to the USA. In Brazil, more than 100,000 accidents were registered in the last 5 years with a total of 303 deaths. To treat such massive attacks, Brazilian researchers developed the first specific antivenom against Africanized honey bee sting exposure. This unique product, the first of its kind in the world, has been safely tested in 20 patients during a Phase 2 clinical trial. To develop the antivenom, a standardize...
Equine Rotavirus A under the One Health Lens: Potential Impacts on Public Health.
Viruses    January 16, 2024   Volume 16, Issue 1 130 doi: 10.3390/v16010130
Carossino M, Vissani MA, Barrandeguy ME, Balasuriya UBR, Parreño V.Group A rotaviruses are a well-known cause of viral gastroenteritis in infants and children, as well as in many mammalian species and birds, affecting them at a young age. This group of viruses has a double-stranded, segmented RNA genome with high genetic diversity linked to point mutations, recombination, and, importantly, reassortment. While initial molecular investigations undertaken in the 1900s suggested host range restriction among group A rotaviruses based on the fact that different gene segments were distributed among different animal species, recent molecular surveillance and genome c...
Inflammatory markers for differentiation of endometritis in the mare.
Equine veterinary journal    January 14, 2024   doi: 10.1111/evj.14058
Lection J, Wagner B, Byron M, Miller A, Rollins A, Chenier T, Cheong SH, Diel de Amorim M.Endometrial biopsy is required to diagnose mares with chronic endometritis and endometrial degenerative fibrosis. An increase in understanding of equine reproductive immunology could be utilised to create less-invasive, time-efficient diagnostic tools especially when evaluating mares for chronic endometritis. Objective: To evaluate inflammatory cytokine and chemokine concentrations in uterine fluid samples collected by low-volume lavage (LVL) as a potential screening diagnostic biomarker for endometritis. Methods: Prospective cross-sectional clinical study. Methods: Forty-six mares underwent a...
A diverse microbial community and common core microbiota associated with the gonad of female Parascaris spp.
Parasitology research    December 18, 2023   Volume 123, Issue 1 56 doi: 10.1007/s00436-023-08086-w
Cain JL, Norris JK, Swan MP, Nielsen MK.The microbiome plays an important role in health, where changes in microbiota composition can have significant downstream effects within the host, and host-microbiota relationships can be exploited to affect health outcomes. Parasitic helminths affect animals globally, but an exploration of their microbiota has been limited, despite the development of anti-Wolbachia drugs to help control infections with some filarial nematodes. The equine ascarids, Parascaris spp., are considered the most pathogenic nematodes affecting juvenile horses and are also the only ascarid parasite to have developed wi...
Immunoproteomics reveal increased serum IgG3/5 binding to Dermatophagoides and yeast protein antigens in severe equine asthma in a preliminary study.
Frontiers in immunology    December 15, 2023   Volume 14 1293684 doi: 10.3389/fimmu.2023.1293684
Schnabel CL, Jentsch MC, Lübke S, Kaiser-Thom S, Gerber V, Vrtala S, Huang HJ, Rhyner C, Wagner B, Hoffmann R, Volke D.Severe equine asthma (SEA) is a common, chronic respiratory disease of horses characterized by hyperreactivity to hay dust which has many similarities to severe neutrophilic asthma in humans. SEA-provoking antigens have not been comprehensively characterized, but molds and mites have been suggested as relevant sources. Here, we identified relevant antigen candidates using immunoproteomics with IgG isotype-binding analyses. Proteins from () were separated by two-dimensional gel electrophoresis followed by immunoblotting (2D immunoblots) resulting in a characteristic pattern of 440 spots. After...
Identification of T cell and linear B cell epitopes on African horse sickness virus serotype 4 proteins VP1-1, VP2, VP4, VP7 and NS3.
Vaccine    December 14, 2023   Volume 42, Issue 2 136-145 doi: 10.1016/j.vaccine.2023.12.028
Faber E, van Schalkwyk A, Ivy Tshilwane S, Van Kleef M, Pretorius A.The viral proteins VP1-1, VP2, VP4, VP7 and NS3, of African horse sickness virus serotype 4 (AHSV4), have previously been identified to contain CD8+ T cell epitopes. In this study, overlapping peptides spanning the entire sequences of these AHSV4 proteins were synthesized and used to map epitopes. Peripheral blood mononuclear cells (PBMC) isolated from five horses immunized with an attenuated AHSV4 were stimulated in vitro with the synthesized peptides. Various memory immune assays were used to identify the individual peptides that contain CD8+ T cell epitopes, CD4+ T cell epitopes and linear ...
Equine ANP32 proteins support influenza A virus RNA polymerase activity.
Virologica Sinica    October 27, 2023   Volume 38, Issue 6 951-960 doi: 10.1016/j.virs.2023.10.009
Zhang Y, Guo X, Yu M, Sun L, Qu Y, Guo K, Hu Z, Liu D, Zhang H, Wang X.Host ANP32 family proteins are crucial for maintaining the activity of influenza RNA polymerase and play an important role in the cross-species transmission of influenza viruses. To date, the molecular properties of equine ANP32 (eqANP32) protein are poorly understood, particularly the mechanisms that affect equine influenza virus (EIV) RNA polymerase activity. Here, we found that there are six alternative splicing variants of equine ANP32A (eqANP32A) with different levels of expression. Further studies showed that these six splicing variants of eqANP32A supported the activity of EIV RNA polym...
Molecular and Serological Survey of Severe Fever with Thrombocytopenia Syndrome Virus in Horses from the Republic of Korea.
Vector borne and zoonotic diseases (Larchmont, N.Y.)    September 8, 2023   doi: 10.1089/vbz.2022.0101
Han SW, Cho YK, Rim JM, Kang JG, Choi KS, Chae JS. Severe fever with thrombocytopenia syndrome (SFTS) is an emerging zoonotic tick-borne disease in East Asia caused by the SFTS virus (SFTSV). It is to investigate the presence of SFTSV RNA and antibodies in horses from a slaughterhouse and equestrian centers in the Republic of Korea (ROK). A prevalence study of SFTSV-specific RNA and antibodies was designed from 889 horses in the ROK. Serum samples were collected from horses at a slaughterhouse and equestrian centers from 2018 to 2020. To detect the presence of SFTSV, RNA was extracted from the serum samples, and a nested reverse transcriptio...
Streptococcus zooepidemicus Meningitis in an HIV-Positive Horse Breeder Patient: A Case Study and Literature Review.
Infectious disease reports    September 7, 2023   Volume 15, Issue 5 527-534 doi: 10.3390/idr15050052
subsp. is a rare etiologic agent of bacterial meningitis in humans. The disease is a zoonotic infection and is transmitted through close contact with domestic animals, mainly horses. Only 37 cases of meningitis have been reported in the literature until July 2023. The aim of this study is to present a rare clinical case of -related meningitis in a human immunodeficiency virus (HIV)-positive patient and analyze the literature. We present a 23-year-old horse breeder patient with advanced immunosuppression due to acquired immunodeficiency syndrome (AIDS) and meningitis, admitted at the Clinic...
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