research article frequencies of blood group systems mns,...

Research ArticleFrequencies of Blood Group Systems MNS Diego and Duffy andClinical Phases of Carrionrsquos Disease in Amazonas Peru

Oscar Acosta123 Luis Solano1 Jorge Escobar4 Miguel Fernandez5

Carlos Solano1 and Ricardo Fujita2

1 Institute of Tropical Medicine Daniel A Carrion Faculty of Medicine Major National University of San Marcos Lima Peru2Genetics and Molecular Biology Center Faculty of Medicine University of San Martin of Porres Lima Peru3 Institute of Biological Chemistry Microbiology and Biotechnology Faculty of Pharmacy and BiochemistryMajor National University of San Marcos Lima Peru

4 Peruvian Ministry of Health (MINSA) Direction of the Sub Region of Health Bagua Bagua Grande Amazonas Peru5 Peruvian Ministry of Health (MINSA) General Direction of Environmental Health (DIGESA) Lima Peru

Correspondence should be addressed to Oscar Acosta oacostacyahoocom

Received 31 August 2013 Revised 7 February 2014 Accepted 20 February 2014 Published 31 March 2014

Academic Editor Jose G Estrada-Franco

Copyright copy 2014 Oscar Acosta et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Carrionrsquos disease (CD) is a human bartonellosis that is endemic in the Andes of Peru Ecuador and Colombia Bartonellabacilliformis a native hemotrophic bacteria is the causative agent of CD and the interaction with the host could have producedchanges in the gene frequencies of erythrocyte antigens The goal here is to investigate the relationship between allele frequenciesof blood group systems MNS Diego and Duffy and the clinical phases of CD within a genetic context In this associative andanalytical study 76 individuals from Bagua Grande the province of Utcubamba and the department of Amazonas in Peru wereenrolled Forty of them resided in Tomocho-Collicate-Vista Hermosa area (high prevalence of cases in chronic phase verrucousor eruptive phase without previous acute phase) Thirty-six individuals were from the area of Miraflores (high prevalence of casesin acute phase only) and were evaluated for blood group systems MNS Diego and Duffy This study constitutes one of the firstattempts at evaluating the genetic factors and clinical phases of CD No significant statistical differences (119875 gt 005) between allelefrequencies of blood groups MNS Diego and Duffy and the prevalence of chronic and acute phases were detected in the two areasof Amazonas Peru

1 Introduction

Carrionrsquos disease (CD) is a human bartonellosis an infec-tious pathology caused by Bartonella bacilliformis (B bacil-liformis) a bacteria native to the Andes which is able toenter the bloodstream and parasitically invade erythrocytes(Figure 1) It is transmitted to humans through the bite ofhematophagous insects of the genus Lutzomyia mainly thespecies L verrucarum [1 2] At present it is endemic inthe Andes (between 500m and 3200 meters above sea level)and the coastal and Amazonian and inter-Andean valleys ofPeru Ecuador and Colombia However it has recently beenfound to be spreading and emerging in lower ecosystemsin some coastal and Amazonian locations In Peru humanbartonellosis has been found in different regions along the

Andes such as Piura Amazonas Cajamarca La LibertadAncash Lima Huancavelica Ayacucho and Cusco [3 4]

TheCarrion disease has been divided in to several clinicalphases two of the most remarkable are as follows (1) thehematic or acute phase known as ldquoOroya feverrdquo commonsymptoms of which are fever hemolytic anemia cephaleapallormyalgias artharlgias and loss of consciousness and (2)the eruptive or verrucous phase termed ldquoverruga peruanardquo(Peruvian wart) which appears after the recovery from theacute phase reddish verrucous eruptive lesions of differentsizes and shapes characterize this phase in some casespatients without a history of the acute illness can display thisphase [4 5]

In endemic areas the presence of asymptomatic carriersis important research so far has indicated humans to be

Hindawi Publishing CorporationInterdisciplinary Perspectives on Infectious DiseasesVolume 2014 Article ID 576107 8 pageshttpdxdoiorg1011552014576107

2 Interdisciplinary Perspectives on Infectious Diseases

NE

BN

Figure 1 Blood smear of patient in acute phase Parasitizederythrocytes by bacillary and coccoid forms of B bacilliformis(arrows) a nucleated erythrocyte (NE) and a band neutrophil (BN)can be observed Giemsa stain 1000x

the only reservoir of the bacterium Evidence suggests thatoutbreaks of bartonellosis represent the emergence in areasof nonendemicity or the resurgence of the disease whichappears to be an infectious emerging or reemerging pathol-ogy with a wide geographic range [4 6]

Several studies [1 5 7] have been conducted with theclinical aspects traditional epidemiology geographical dis-tribution and molecular biology of the bacterium and othertopics related to B bacilliformis Epidemiological data showsthat in some closely situated Peruvian areas differences in thepredominance of the CDphases can be noted Comparison ofthe clinical phases in localities within the district of BaguaGrande Amazonas department showed different distribu-tions of either the verrucous or hematic phases In Tomocho-Collicate-Vista Hermosa there was a prevalence of verrucouscases (81 affected individuals versus 5 hematic occurrences)whereas in the nearby location of Miraflores there were 12hematic cases and only 5 verrucous affected individuals Thisinformation was obtained by MF and JE (data not published)and Records of the EpidemiologicalWeekN∘ 32 August 2004(provided by Epidemiological Office Subregion of Bagua-Amazonas Ministry of Health)

The local population is apparently mestizo (mostlyAndean and Caucasian genetic background) most of whomare migrants coming from the Andean department of Caja-marca (communication of Subregion of Bagua-Amazonas)

Genetic factors can exert a great influence on the sus-ceptibility resistance andor tolerance to infectious diseasenot only at an individual but also at a population level Itis well known that some genetic traits considered of riskare present in modern human populations and that theyarise independently due to selective pressure of infectionsThus mutant globins glucose-6-phosphate dehydrogenase(G6PD) and Duffy antigen genes are paradigmatic examplesof malaria protection An abnormally high prevalence ofdeleterious mutant alleles is present in populations of theTropical Belt areas around the world For example theenzyme G6PD is involved in malaria protection but itshomozygous state predisposes to hemolytic anemia Peoplewith an absent Duffy antigen are also protected against

malaria by Plasmodium vivax (P vivax) because the pathogenuses it to invade erythrocytes [8ndash11]

Very little information is available from South Americanpopulations about this aspect There are native parasites thatcause endemic diseases since pre-Columbian times such asTrypanosoma cruzi Leishmania peruviana and B bacilli-formis [12 13] and it is possible that they have influenced thedistribution of different alleles by selective pressure Althoughthe malaria is important the pre-Columbian presence of Pvivax has been subject to great debate and remains unclear[14]

We postulate that Amerindian hosts have possibly devel-oped mechanisms of susceptibility resistance or tolerancewith regard to genetic composition which may be associatedwith the clinical phases of CD One strategy to test thishypothesis is to search for genes or molecular markers inwhich selective pressure can be exerted by B bacilliformis andto evaluate the variation of allele frequencies of the genes inhuman populations

Specifically this can be verified by variation of ery-throcyte antigens (receptor molecules for the bacterium)and cellular and humoral immunity According to Bucklesand McGinnis [15] glycophorins AB and band 3 act asreceptors forB bacilliformis adhesion and invasionmoleculessuch as flagellin adhesin deformin IaIA and IaIB Gly-cophorins AB and band 3 are closely related with bloodgroup systems MNS and Diego [16] On the other handDuffy group is associated with resistance to malaria by Pvivax in populations living in endemic areas in Africa andOceania [17 18] It is possible that in Bartonella infectionDuffy glycoproteins are involved as receptormoleculesThusvariability or polymorphisms of blood group systems couldbe related with susceptibility resistance andor tolerance toinfection aswell aswith the prevalence of the diseasersquos clinicalphases

In this study genetic and coevolutionary principles areapplied in order to investigate the relationship between thegenetics of Amerindian host and clinical phases of CD aninfectious pathology that can be found inmost of the Andeandepartments of Peru

Specifically the goal is to investigate the relationshipbetween clinical phases of CD and the allele frequenciesof blood group systems MN Ss Diego and Duffy undera genetic coevolutionary context that is under selectivepressure of B bacilliformis over the Amerindian host Thisresearch is one of the first attempts to evaluate genetic factorsand clinical phases of this ancient disease from the AndesFor this purpose we have taken advantage of the differ-ences between Tomocho-Collicate-Vista Hermosa (predomi-nance of verrucous phase) and Miraflores (predominance ofhematic disease) We will compare the allele frequencies ofthe blood group systems MN Ss Diego and Duffy betweenthese two areas

2 Materials and Methods

21 Areas of Study and Participants CD is endemic withinthe area of study corresponding to the district of Bagua

Interdisciplinary Perspectives on Infectious Diseases 3

Grande (05∘4610158404010158401015840 South 78∘2510158404610158401015840 West) province ofUtcubamba department of Amazonas in the NorthernUpper Amazonian Jungle of Peru at 540 meters above sealevel (Figure 2) We have analyzed samples at two locationswith different prevalence of either the verrucose or hematicforms according to the Annual Report and EpidemiologicBulletin Subregion of Health Bagua-Amazonas Peru 2004General and clinical data was collected for each of the 40individuals from Tomocho-Collicate-Vista Hermosa locali-ties (prevalence verrucose form or chronic phase) and for the36 fromMiraflores district (prevalence hematic form or acutephase) using convenience sampling

22 Biological Sample The sampling was performed inSeptember 2004 (Epidemiological Week no 36) Each ofthe 76 individuals signed a written consent form beforesamples were collected Five to 10mL of peripheral bloodwere collected in Vacutainer sterile tubes (Becton Dickin-son Franklin Lakes NJ) containing anticoagulant EDTA orsodium citrate The samples were kept under refrigerationuntil they were processed for blood groups at the Laboratoryfor Bartonellosis Daniel A Carrion Tropical Medicine Insti-tute UniversidadNacionalMayor de SanMarcos (UNMSM)This study was presented to and approved by the Scientificand Ethic Committee Faculty of Medicine UNMSM Inaddition the project was approved and authorized by theSubregional Director of Health in Amazonas and BaguarsquosHospital

23 Determination of Blood Groups Blood typing was per-formed according to antisera manufacturerrsquos specifications(Immucor Gamma Biological USA) group MN was deter-mined by monoclonal anti-M and anti-N antisera through adirect method in test tubes While blood groups Ss Diegoand Duffy were determined by polyclonal anti-S anti-santi-Dia anti-Fya and anti-Fyb antisera through HumanAntiglobulin test and test tube method

24 Statistical Analysis Allele frequencies based on pheno-type frequencies were obtained by a direct countingmethodIn order to evaluate the frequencies a Chi-square test (1205942)was used to estimate the Hardy-Weinberg equilibrium A 1205942or Fisherrsquos exact test was applied to establish allelic associationof blood groups and clinical phases according to the areaSPSS 150 statistical software andpopulation genetics softwarewere used for calculations

3 Results

As may be seen in Table 1 we sampled 40 individuals inTomocho-Collicate-Vista Hermosa (prevalence of chronicform) 17 of which (425) were males and 23 were females(575) The average age was 235 with a standard deviationof plusmn106The prevalent clinical phase was the chronic form in22 cases (575) with only one case of the acute phase (25)CD was not found in 17 (425) of individuals

The Miraflores group (prevalence of acute form) con-sisted of 36 individuals 14 males (389) and 22 females

Figure 2 Location of the sampled areas in BaguaGrande (red spot)province of Utcubamba department of Amazonas Peru At left topmap of Peru with location of department (filled in red)

(611) The average age was 29 with a standard deviationof plusmn229 Of these 36 individuals 12 presented with onlyacute phase (333) 23 were healthy (638) and onecase displayed the chronic and acute phases simultaneously(27)

The biased and compartmentalized distribution of dis-tinct clinical phases in two different but geographicallyproximal areas Tomocho-Collicate-Vista Hermosa (preva-lence of verrucous phase) and Miraflores (prevalence ofhematic phase) promoted us to compare the distribution ofphenotype frequencies of theMN Ss Diego andDuffy bloodgroup systems in both areas

We performed the analysis of the phenotype frequenciesof the MN Ss Diego and Duffy blood group systemsand found that they were in Hardy-Weinberg equilibrium(Table 2) Thus at this moment we do not have any evidenceof selective pressure on these blood systems The frequenciesof blood group systemswere similar in both areas and theMNblood group system was the most variable

For the MN blood system an increase in the frequency ofheterozygotes in Tomocho-Collicate-Vista Hermosa (MM =0375 MN = 0575) was found in comparison to Miraflores(MM = 05 MN = 0389) but it was not statistically sig-nificant However when the alleles were compared a muchnarrower distributionwas found inTomocho-Collicate-VistaHermosa the M = 06625 and N = 03375 versus M =06945 and N = 03055 in Miraflores In both comparisonsof distributions of phenotypes and allele frequencies of MNblood group no significant statistical differences were foundbetween the two areas (Table 2)

In the comparisons of blood group systems Ss Diego andDuffy no evident differences were seen either in phenotypes


Table 1 General data and clinical phases of the samples analyzed in this study

Characteristics Tomocho-Collicate-Vista Hermosa Miraflores119899 () 119899 ()

Sample 40 36Sex

Male 17 (425) 14 (389)Female 23 (575) 22 (611)Total 40 (1000) 36 (1000)

Age119883 plusmn SD years 235 plusmn 106 295 plusmn 229

Clinical phaseslowast

Acute phase only 1a 12Chronic phase only 22 0Acute and chronic phases 0 1b

No reported disease or healthy 17 23Total 40 36Total for analysis 39a 35b

119883 plusmn SD is the median plusmn standard deviationlowastClinical phasesrsquo data of each individual were obtained by self-report (personal interviews) andor review of clinical records for verification of treatment orsupervision of the Carrionrsquos diseaseaOne individual had acute phase and was removed from the analysis ldquoblood group versus clinical phaserdquo in Tomocho-Collicate-Vista Hermosa area reducingour sample from 40 to 39 individualsbOne individual had acute and chronic phases and was removed from the analysis ldquoblood group versus clinical phaserdquo in Miraflores area reducing our samplefrom 36 to 35 individuals

or allelesThere was therefore an absence of statistical differ-ences in all blood group systems with regard to phenotypesand allele frequencies in the two areas (Table 2)

To test the hypothesis that the clinical phases of CD areassociatedwith blood groups we seek the possible associationbetween phenotypes and alleles of MN Ss Diego andDuffy with the benign (chronic or verrucose) and nonbenign(acute or hematic) clinical phases Forty individuals werefromTomocho-Collicate-VistaHermosa districts (prevalenceof the verrucose phase) and 36 from Miraflores district(prevalence of the hematic phase) It may be seen howeverthat in each group there was one atypical individual forthe prevalence of the respective location (one acute case inTomocho-Collicate-Vista Hermosa and one chronic case inMiraflores) These individuals were removed for subsequentanalysis Therefore we have selected 39 individuals fromTomocho-Collicate-Vista Hermosa 22 cases of chronic phaseand 17 with no bartonellosis registered and from Mirafloreswe have 35 individuals 12 cases of acute phase and 23 with nobartonellosis (Table 3)

The differences of phenotype or alleles among casesversus occurrences of no bartonellosis in each area arenonsignificant statistical We have also compared the clinicalphases and phenotypes or alleles frequencies between areasand again no significant statistical differences were found(Table 3)

4 Discussion and Conclusion

Carrionrsquos disease a human bartonellosis is characterized bytwo well defined clinical phases One phase is the hematic

anemic febrile or acute phase that is devastating and may befatal and the other is the chronic eruptive verrucous phasethat is a benign phase [3]

The present and previous work have shown that there isan evident difference of the distribution of the acute and thechronic CD phases in the district of Bagua Grande (MF andJE not published results and Annual Report and Epidemi-ologic Bulletin Subregion of Health Bagua-Amazonas Peru2004) The reason why Tomocho-Collicate-Vista Hermosadisplays high prevalence of the chronic phase and Miraflorespredominantly displays the acute phase remains withoutexplanation at present A differential genetic response of thehost could be invoked but at this time there is no historicalor cultural information concerning the ethnic backgroundsof Miraflores versus Tomocho-Collicate-Villa Hermosa resi-dents Under the same logic distinct genotypes-phenotypeslinked to a differential distribution of B bacilliformis strainsor Lutzomyia spp vector may also be hypothesized but as yetno proof has been found Molecular genetic characterizationof the pathogen and vector species in bartonellosis needsto be taken into account for future studies concerning thedifferential distribution in the district of Bagua Grande

A study regarding the mechanisms of B bacilliformisinvasion has revealed the participation of erythrocyte anti-gens (glycophorins AB and band 3) Since these moleculesare closely related to blood group systems MN Ss Diego[15] and Duffy group it is possible that they could beinvolved as receptor molecules All of these proteins arepresent in the erythrocyte membranes and are involved inthe entrance of pathogens like Plasmodium Homozygousdefective mutations for these proteins have been reported


Table2Distrib

utionof

bloo

dgrou

psyste

msb

yareaB

aguaA

mazon

asPeru

Group

Phenotypes

Tomocho

-Collicate-VistaH

ermosa

Mira

flores

119875ph

enotypes119875alleles

119899=40

Phenotypefrequ

ency

Allele

Allelefre

quency119899=36

Phenotypefrequ

ency

Allele

Allelefre

quency

MN

MM

150375

M06625

180500

M06945

0232

0674

MN

230575

N03375

140389

N03055

NN

20050

40111

SsSS

100250

S05625

100278

S05835

0955

0796

Ss25

0625

s04375

220611

s04165

Ss5

0125

40111

Diego

Di(a+

)6

0150

Dia

00750

70194

Dia

00972

0607

0625

Di(aminus

)34

0850

NoDia

09250

290806

NoDia

09027

Duff

y

Fy(a+bminus

)14

0350

Fya

05750

130361

Fya

05695

0952

0945

Fy(a+b+

)18

0450

Fyb

04250

150417

Fyb

04305

Fy(aminusb+

)8

0200

80222

Fy(aminusbminus

)0

000

00

000

0Ph

enotypefre

quencies

(inthiscase

also

geno

type)o

fMN

bloo

dgrou

psyste

mthe

mostv

ariablearein

Hardy-W

einb

ergequilib

rium

(119875gt005C

hi-squ

aretest)

Inthecomparis

onso

fpheno

typesa

ndallele

frequ

encies

ofbloo

dgrou

psyste

msno

significantstatisticaldifferences

(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthetwoareas


Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH

ermosa(119899=39)lowast

Mira

flores(119899=35)lowast

Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho

-Collicate-VistaHermosahadacuteph

aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas


as being protective for malarial infection in Africa and Asia[19] Very little information is available from South Americanpopulations but some studies in Brazil and Colombia haveconfirmed that Duffy MN and Ss variant blood groups areresistant to P falciparum infection in some populations [20ndash22] although this concerns the protozoan studies in bacteriasuch as B bacilliformis are currently underway

In our hypothesis we postulated that selective pressureexerted by this bacterium could have determined differentphenotype frequencies of the blood groups from each areaunder study Our results indicate no relationship betweenblood groups and locations that have biased prevalenceeither with the chronic phase (Tomocho-Collicate-Vista Her-mosa) or the acute phase (Miraflores) Phenotypes andallele of blood group systems MN Ss Diego and Duffydo not show a statistically significant (119875 gt 005) differ-ence between the frequencies found in Tomocho-Collicate-Vista Hermosa compared with the frequencies in Miraflores(Table 2)

Although there was no significant difference (119875 gt 005)in the MN blood group which is in Hardy-Weinberg equilib-rium in both areas the incidence of heterozygositywas higherin Tomocho-Collicate-Vista Hermosa than inMiraflores It istherefore tempting to speculate a heterozygote advantage inTomocho-Collicate-VistaHermosa favoring the chronic stateIt should however be noted that the nonstatistically relevantdifferences outlined above could result from the small samplesize of this investigation

The general tendency of no association found with MNand clinical phase continues when we compare Ss Diego andDuffy blood group systems alleles with nonaffected individu-als and cases of chronic and acute phases (Table 3) Howeverthese datamust be considered as preliminary in order tomakegeneral inferences about the infection associated with bloodgroup systems or erythrocyte antigens Other gene variantsassociated with infectious processes such as genes for toll-likereceptors interleukins lectins HLA cytokines and otherproteins of the innate and acquired immunoinflammatoryresponses including microRNA polymorphisms expressionexomes and ancestry informativemarkers (AIMs) need to betestedMoreovermolecular genetic analysis of bacteriumandgenetic variability of insect vectors should also be considered[8 23 24]

On one hand the results of this study cannot be extrap-olated to other regions of Peru where the disease is alsofound since there are differences in the genetic compositionof Peruvian subpopulations The prevalence of the clini-cal phase and history of outbreaks and reappearances [7]will be very important information when exploring geneticstudies amongst these subpopulations On the other handthis study has contributed to the knowledge concerningthe genetic variability of subpopulations of Bagua GrandeAmazonas

In conclusion our results showed no significant statisticaldifferences between allele frequencies of blood groups MNSDiego and Duffy and the prevalence of clinical phases of theCarrionrsquos disease in the district of Bagua Grande departmentof Amazonas Peru

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

Theauthors thank the people and authorities fromTomocho-Collicate-Vista Hermosa and Miraflores in Bagua GrandeAmazonas for their support in this study In addition theywish to express their sincere gratitude to health personnelfrom both areas including Dr Isaac Palma and Dr AndresCordoba for their valuable collaboration They also thankMatt Bawn PhD for a detailed review of English Fortheir financial support they wish to also thank the Facultyof Medicine Universidad Nacional Mayor de San Marcos(Proyecto FEDU) and the Faculty of Human MedicineUniversidad de San Martın de Porres (Proyecto Inmuno-geneticamdashE10012014022)

References

[1] G C Gray A A Johnson S A Thornton et al ldquoAn epidemicof Oroya fever in the Peruvian Andesrdquo American Journal ofTropical Medicine and Hygiene vol 42 no 3 pp 215ndash221 1990

[2] L Solano and V Solano ldquoLa Enfermedad de Carrion y laBiologıa de Bartonella bacilliformisrdquo Revista Peruana de Medic-ina Tropical UNMSM vol 5 pp 13ndash18 1991

[3] C Maguina Bartonelosis o Enfermedad de Carrion Nuevosaspectos de una vieja enfermedad Editor Importadores LimaPeru 1998

[4] OGEINS Epidemiologıa de la Bartonelosis en el Peru SerieDocumentos Monograficos Modulos Tecnicos Lima Peru2000

[5] M Kosek R Lavarello R Gilman et al ldquoNatural Historyof Infection with Bartonella bacilliformis in a NonendemicPopulationrdquo The Journal of Infectious Diseases vol 3 pp 865ndash872 2000

[6] L Solano L Marocho A Caceres et al ldquoEstudio de reservoriosde Bartonella bacilliformisrdquo Revista Peruana de Medicina Tropi-cal UNMSM vol 1 pp 71ndash74 2004

[7] G Greub and D Raoult ldquoBartonella new explanations for olddiseasesrdquo Journal ofMedicalMicrobiology vol 51 no 11 pp 915ndash923 2002

[8] G Aguileta G Refregier R Yockteng E Fournier and TGiraud ldquoRapidly evolving genes in pathogens methods fordetecting positive selection and examples among fungi bacte-ria viruses and protistsrdquo Infection Genetics and Evolution vol9 no 4 pp 656ndash670 2009

[9] G S Cooke and A V S Hill ldquoGenetics of susceptibility tohuman infectious diseaserdquo Nature Reviews Genetics vol 2 no12 pp 967ndash977 2001

[10] R Medzhitov ldquoDamage control in host-pathogen interactionsrdquoProceedings of the National Academy of Sciences of the UnitedStates of America vol 106 no 37 pp 15525ndash15526 2009

[11] D J Weatherall J I Bell J B Clegg et al ldquoGenetic factorsas determinants of infectious disease transmission in humancommunitiesrdquo Philosophical Transactions of the Royal Societyof London B Biological sciences vol 321 no 1207 pp 327ndash3481988


[12] M J Allison A Pezzia E Gerszten and D Mendoza ldquoA caseof Carrionrsquos disease associated with human sacrifice from theHuari culture of Southern Perurdquo American Journal of PhysicalAnthropology vol 41 no 2 pp 295ndash300 1974

[13] J Verano and G Lombardi ldquoPaleopatologıa en Sudamericaandinardquo Bulletin de lrsquoInstitut Francais drsquoEtudes Andines vol 1pp 91ndash121 1999

[14] L A Cormier ldquoThe historical ecology of human and wildprimate malarias in the new worldrdquo Diversity vol 2 no 2 pp256ndash280 2010

[15] E L Buckles andEMcGinnis ldquoInteraction ofBartonella bacilli-formis with human erythrocyte membrane proteinsrdquoMicrobialPathogenesis vol 29 no 3 pp 165ndash174 2000

[16] ldquoSCARF (Serum Cells and Rare Fluid Exchange)rdquo httpscarfexjoveprohostingcomexchangehistoryhtml

[17] A G Maier M T Duraisingh J C Reeder et al ldquoPlasmodiumfalciparum erythrocyte invasion through glycophorin C andselection for Gerbich negativity in human populationsrdquo NatureMedicine vol 9 no 1 pp 87ndash92 2002

[18] L H Miller S J Mason D F Clyde and M H McGinnissldquoThe resistance factor to Plasmodium vivax in blacks TheDuffy blood group genotype FyFyrdquo The New England Journalof Medicine vol 295 no 6 pp 302ndash304 1976

[19] D P Blackall J K Armstrong H J Meiselman and T CFisher ldquoPolyethylene glycolmdashcoated red blood cells fail tobind glycophorin Amdashspecific antibodies and are impervious toinvasion by thePlasmodium falciparummalaria parasiterdquoBloodvol 97 no 2 pp 551ndash556 2001

[20] B Beiguelman F P Alves M M Moura et al ldquoThe associationof genetic markers and malaria infection in the Brazilianwestern Amazonian regionrdquo Memorias do Instituto OswaldoCruz vol 98 no 4 pp 455ndash460 2003

[21] C E Cavasini L C deMattos R T Alves et al ldquoFrequencies ofABO MNSs and Duffy phenotypes among blood donors andmalaria patients from four Brazilian Amazon areasrdquo HumanBiology vol 78 no 2 pp 215ndash219 2006

[22] F Montoya M Restrepo A E Montoya and W Rojas ldquoBloodgroups and malariardquo Revista do Instituto de Medicina Tropicalde Sao Paulo vol 36 no 1 pp 33ndash38 1994

[23] L Abel and A J Dessein ldquoThe impact of host genetics onsusceptibility to human infectious diseasesrdquo Current Opinion inImmunology vol 9 no 4 pp 509ndash516 1997

[24] A V S Hill ldquoThe genomics and genetics of human infectiousdisease susceptibilityrdquo Annual Review of Genomics and HumanGenetics vol 2 pp 373ndash400 2001

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


NE

BN

Figure 1 Blood smear of patient in acute phase Parasitizederythrocytes by bacillary and coccoid forms of B bacilliformis(arrows) a nucleated erythrocyte (NE) and a band neutrophil (BN)can be observed Giemsa stain 1000x

the only reservoir of the bacterium Evidence suggests thatoutbreaks of bartonellosis represent the emergence in areasof nonendemicity or the resurgence of the disease whichappears to be an infectious emerging or reemerging pathol-ogy with a wide geographic range [4 6]

Several studies [1 5 7] have been conducted with theclinical aspects traditional epidemiology geographical dis-tribution and molecular biology of the bacterium and othertopics related to B bacilliformis Epidemiological data showsthat in some closely situated Peruvian areas differences in thepredominance of the CDphases can be noted Comparison ofthe clinical phases in localities within the district of BaguaGrande Amazonas department showed different distribu-tions of either the verrucous or hematic phases In Tomocho-Collicate-Vista Hermosa there was a prevalence of verrucouscases (81 affected individuals versus 5 hematic occurrences)whereas in the nearby location of Miraflores there were 12hematic cases and only 5 verrucous affected individuals Thisinformation was obtained by MF and JE (data not published)and Records of the EpidemiologicalWeekN∘ 32 August 2004(provided by Epidemiological Office Subregion of Bagua-Amazonas Ministry of Health)

The local population is apparently mestizo (mostlyAndean and Caucasian genetic background) most of whomare migrants coming from the Andean department of Caja-marca (communication of Subregion of Bagua-Amazonas)

Genetic factors can exert a great influence on the sus-ceptibility resistance andor tolerance to infectious diseasenot only at an individual but also at a population level Itis well known that some genetic traits considered of riskare present in modern human populations and that theyarise independently due to selective pressure of infectionsThus mutant globins glucose-6-phosphate dehydrogenase(G6PD) and Duffy antigen genes are paradigmatic examplesof malaria protection An abnormally high prevalence ofdeleterious mutant alleles is present in populations of theTropical Belt areas around the world For example theenzyme G6PD is involved in malaria protection but itshomozygous state predisposes to hemolytic anemia Peoplewith an absent Duffy antigen are also protected against

malaria by Plasmodium vivax (P vivax) because the pathogenuses it to invade erythrocytes [8ndash11]

Very little information is available from South Americanpopulations about this aspect There are native parasites thatcause endemic diseases since pre-Columbian times such asTrypanosoma cruzi Leishmania peruviana and B bacilli-formis [12 13] and it is possible that they have influenced thedistribution of different alleles by selective pressure Althoughthe malaria is important the pre-Columbian presence of Pvivax has been subject to great debate and remains unclear[14]

We postulate that Amerindian hosts have possibly devel-oped mechanisms of susceptibility resistance or tolerancewith regard to genetic composition which may be associatedwith the clinical phases of CD One strategy to test thishypothesis is to search for genes or molecular markers inwhich selective pressure can be exerted by B bacilliformis andto evaluate the variation of allele frequencies of the genes inhuman populations

Specifically this can be verified by variation of ery-throcyte antigens (receptor molecules for the bacterium)and cellular and humoral immunity According to Bucklesand McGinnis [15] glycophorins AB and band 3 act asreceptors forB bacilliformis adhesion and invasionmoleculessuch as flagellin adhesin deformin IaIA and IaIB Gly-cophorins AB and band 3 are closely related with bloodgroup systems MNS and Diego [16] On the other handDuffy group is associated with resistance to malaria by Pvivax in populations living in endemic areas in Africa andOceania [17 18] It is possible that in Bartonella infectionDuffy glycoproteins are involved as receptormoleculesThusvariability or polymorphisms of blood group systems couldbe related with susceptibility resistance andor tolerance toinfection aswell aswith the prevalence of the diseasersquos clinicalphases

In this study genetic and coevolutionary principles areapplied in order to investigate the relationship between thegenetics of Amerindian host and clinical phases of CD aninfectious pathology that can be found inmost of the Andeandepartments of Peru

Specifically the goal is to investigate the relationshipbetween clinical phases of CD and the allele frequenciesof blood group systems MN Ss Diego and Duffy undera genetic coevolutionary context that is under selectivepressure of B bacilliformis over the Amerindian host Thisresearch is one of the first attempts to evaluate genetic factorsand clinical phases of this ancient disease from the AndesFor this purpose we have taken advantage of the differ-ences between Tomocho-Collicate-Vista Hermosa (predomi-nance of verrucous phase) and Miraflores (predominance ofhematic disease) We will compare the allele frequencies ofthe blood group systems MN Ss Diego and Duffy betweenthese two areas

2 Materials and Methods

21 Areas of Study and Participants CD is endemic withinthe area of study corresponding to the district of Bagua






3 Results












Sample 40 36Sex
















Table2Distrib

utionof

bloo

dgrou

psyste

msb

yareaB

aguaA

mazon

asPeru

Group

Phenotypes

Tomocho

-Collicate-VistaH

ermosa

Mira

flores

119875ph


119899=40

Phenotypefrequ

ency

Allele

Allelefre

quency119899=36

Phenotypefrequ

ency

Allele

Allelefre

quency

MN

MM

150375

M06625

180500

M06945

0232

0674

MN

230575

N03375

140389

N03055

NN

20050

40111

SsSS

100250

S05625

100278

S05835

0955

0796

Ss25

0625

s04375

220611

s04165

Ss5

0125

40111

Diego

Di(a+

)6

0150

Dia

00750

70194

Dia

00972

0607

0625

Di(aminus

)34

0850

NoDia

09250

290806

NoDia

09027

Duff

y

Fy(a+bminus

)14

0350

Fya

05750

130361

Fya

05695

0952

0945

Fy(a+b+

)18

0450

Fyb

04250

150417

Fyb

04305

Fy(aminusb+

)8

0200

80222

Fy(aminusbminus

)0

000

00

000

0Ph

enotypefre

quencies

(inthiscase

also

geno

type)o

fMN

bloo

dgrou

psyste

mthe

mostv

ariablearein

Hardy-W

einb

ergequilib

rium

(119875gt005C

hi-squ

aretest)

Inthecomparis

onso

fpheno

typesa

ndallele

frequ

encies

ofbloo

dgrou

psyste

msno


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou



Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH


Mira


Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho


aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas










Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















3 Results












Sample 40 36Sex
















Table2Distrib

utionof

bloo

dgrou

psyste

msb

yareaB

aguaA

mazon

asPeru

Group

Phenotypes

Tomocho

-Collicate-VistaH

ermosa

Mira

flores

119875ph


119899=40

Phenotypefrequ

ency

Allele

Allelefre

quency119899=36

Phenotypefrequ

ency

Allele

Allelefre

quency

MN

MM

150375

M06625

180500

M06945

0232

0674

MN

230575

N03375

140389

N03055

NN

20050

40111

SsSS

100250

S05625

100278

S05835

0955

0796

Ss25

0625

s04375

220611

s04165

Ss5

0125

40111

Diego

Di(a+

)6

0150

Dia

00750

70194

Dia

00972

0607

0625

Di(aminus

)34

0850

NoDia

09250

290806

NoDia

09027

Duff

y

Fy(a+bminus

)14

0350

Fya

05750

130361

Fya

05695

0952

0945

Fy(a+b+

)18

0450

Fyb

04250

150417

Fyb

04305

Fy(aminusb+

)8

0200

80222

Fy(aminusbminus

)0

000

00

000

0Ph

enotypefre

quencies

(inthiscase

also

geno

type)o

fMN

bloo

dgrou

psyste

mthe

mostv

ariablearein

Hardy-W

einb

ergequilib

rium

(119875gt005C

hi-squ

aretest)

Inthecomparis

onso

fpheno

typesa

ndallele

frequ

encies

ofbloo

dgrou

psyste

msno


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou



Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH


Mira


Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho


aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas










Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















Sample 40 36Sex
















Table2Distrib

utionof

bloo

dgrou

psyste

msb

yareaB

aguaA

mazon

asPeru

Group

Phenotypes

Tomocho

-Collicate-VistaH

ermosa

Mira

flores

119875ph


119899=40

Phenotypefrequ

ency

Allele

Allelefre

quency119899=36

Phenotypefrequ

ency

Allele

Allelefre

quency

MN

MM

150375

M06625

180500

M06945

0232

0674

MN

230575

N03375

140389

N03055

NN

20050

40111

SsSS

100250

S05625

100278

S05835

0955

0796

Ss25

0625

s04375

220611

s04165

Ss5

0125

40111

Diego

Di(a+

)6

0150

Dia

00750

70194

Dia

00972

0607

0625

Di(aminus

)34

0850

NoDia

09250

290806

NoDia

09027

Duff

y

Fy(a+bminus

)14

0350

Fya

05750

130361

Fya

05695

0952

0945

Fy(a+b+

)18

0450

Fyb

04250

150417

Fyb

04305

Fy(aminusb+

)8

0200

80222

Fy(aminusbminus

)0

000

00

000

0Ph

enotypefre

quencies

(inthiscase

also

geno

type)o

fMN

bloo

dgrou

psyste

mthe

mostv

ariablearein

Hardy-W

einb

ergequilib

rium

(119875gt005C

hi-squ

aretest)

Inthecomparis

onso

fpheno

typesa

ndallele

frequ

encies

ofbloo

dgrou

psyste

msno


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou



Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH


Mira


Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho


aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas










Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Table2Distrib

utionof

bloo

dgrou

psyste

msb

yareaB

aguaA

mazon

asPeru

Group

Phenotypes

Tomocho

-Collicate-VistaH

ermosa

Mira

flores

119875ph


119899=40

Phenotypefrequ

ency

Allele

Allelefre

quency119899=36

Phenotypefrequ

ency

Allele

Allelefre

quency

MN

MM

150375

M06625

180500

M06945

0232

0674

MN

230575

N03375

140389

N03055

NN

20050

40111

SsSS

100250

S05625

100278

S05835

0955

0796

Ss25

0625

s04375

220611

s04165

Ss5

0125

40111

Diego

Di(a+

)6

0150

Dia

00750

70194

Dia

00972

0607

0625

Di(aminus

)34

0850

NoDia

09250

290806

NoDia

09027

Duff

y

Fy(a+bminus

)14

0350

Fya

05750

130361

Fya

05695

0952

0945

Fy(a+b+

)18

0450

Fyb

04250

150417

Fyb

04305

Fy(aminusb+

)8

0200

80222

Fy(aminusbminus

)0

000

00

000

0Ph

enotypefre

quencies

(inthiscase

also

geno

type)o

fMN

bloo

dgrou

psyste

mthe

mostv

ariablearein

Hardy-W

einb

ergequilib

rium

(119875gt005C

hi-squ

aretest)

Inthecomparis

onso

fpheno

typesa

ndallele

frequ

encies

ofbloo

dgrou

psyste

msno


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou



Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH


Mira


Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho


aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas










Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Table3Ph

enotypes

andallelefre

quencies

ofbloo

dgrou

psyste

msa

ccording

clinicalphasesb

yarea

studyB

aguaA

mazon

asPeru

Group

Area

119875b

clinicalphases

betweenareas

Tomocho

-Collicate-VistaH


Mira


Casesinchronic

phaseo

nly(119899=22)

Norepo

rted

disease

(119899=17)

119875a

Casesinacutep

hase

only(119899=12)

Norepo

rted

disease

(119899=23)

119875a

MN

MM

87

0759

512

0555

0761

MN

1210

68

NN

20

13

M28

(06364)

24(07059)

0518

16(06667)

32(06957)

0804

0803

N16

(03636)

10(02941)

8(033

33)

14(03043)

Ss

SS6

40791

36

0944

0886

Ss14

108

14ss

23

13

S26

(05910)

18(052

94)

0587

14(05834)

26(05653)

0884

0952

s18

(04090)

16(04706)

10(04166)

20(04347)

Diego

Di(a+

)4

20679

25

1000

1000

Di(aminus

)18

1510

18Dia

4(00909)

2(00588)

0691

2(00833)

5(010

86)

1000

1000

NoDia

40(09091)

32(09412)

22(09167)

41(08914)

Duff

y

Fy(a+bminus

)8

6

0945

49

0736

0850

Fy(a+b+

)9

86

9Fy

(aminusb+

)5

32

5Fy

(aminusbminus

)0

00

0Fy

a25

(05692)

20(05883)

0859

14(053

34)

27(05870)

0977

0904

Fyb

19(04318)

14(04117)

10(04166)

19(04130)

lowast

One

individu

alof

theTo

mocho


aseandwas

removed

from

thisanalysis

redu

cing

ours

amplefro

m40

to39

individu

alsIn

asim

ilarw

ayone

individu

alfro

mMira

flores

presentedchronicp

hase

andwas

also

removed

from

thea

nalysisreducingthen

umberfrom

36to

35individu

als

a Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringclinicalph

ases

andhealthyindividu

als(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

were

foun

din

each

area

b Inthec

omparis

onso

fpheno

typesa

ndallelefre

quenciescon

sideringon

lyclinicalph

ases

(2times2clu

sters)no


(119875gt005C

hi-squ

areo

rFish

errsquosexacttests)

werefou

ndbetweenthe

twoareas










Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

























Acknowledgments


References































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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