June 25, 1999 

Introduction

Michael's Great Smokies lab reports of 8.7.98, 10.19.98, and 2.8.99 document
intestinal colonization by Klebsiella pneumoniae (Kp) and hemolytic Eschirichia
coli (hEc), which can translocate from gastrointestinal tissue into mesenteric
lymph nodes, peritoneum, and other tissues, including the brain. Whether or not
such translocation has occurred in Michael remains to be determined.

[a]  Focal neurologic deficits can occur in response to sepsis (1a), as can
other CNS-related injuries (eg, 1b-f), including vascular alterations (1e), thus
I wonder about a similar phenomenon in persons without sepsis but having chronic
active bacterial infection in other bodily locations -- eg, blood brain barrier
(1d), sinuses (2), peritonuem, and gastrointestinal tract. Some researchers
imply a range of effects from gram-negative bacteria (1f), suggesting that some
children might have less severe, even subclinical manifestations if the
infection were sufficiently focal, perhaps even confined to vascular cells
without gaining access to the CNS, which is supported by the fact that CSF is
not a preferrred medium for Kp (8).

[b]  A canine study showed the peripheral translocation of bacteria can result
in CNS involvement (3), and brain abscesses can occur in the absence of purulent
meningitis (4); and "prune belly" is associated with various Klebsiella species
(eg, K. oxytoca (6).

[c]  Predisposing conditions to Kp infections can make diagnostic imaging and
treatment more problematic (5a-b); and both Kp and Ec predispose towards intra-
abdominal infections (7).

[d]  If systemic Kp and/or hEc fragments are reaching cells of the blood-brain
barrier, then vascular inflammation could be occurring (9a-b), along with
associated hypoperfusion and hypofuction in adjoining brain regions and neuronal
pathways connected thereto (10), as further delineated on a webpage
http://www.jorsm.com/~binstock/bbb-inf.htm

Teresa Binstock
Researcher in Developmental and Behavioral Neuroanatomy
June 25, 1999

 Summary Why Klebsiella pneumonia and hemolytic E. coli have come to demand much attention in this report. (Kp, hEc)

 Translocation of Kp and hEc

 Peritoneal and abdominal Kp and hEc

 Neurologic aspects of Kp and hEc

 Miscellany regarding Kp and hEc

 Additional tests

 Michael's index page

     A series of autism-spectrum research monographs is available by
     links on a web page: http://www.jorsm.com/~binstock/index.htm

1a. Acta Neurol Scand 1996 Oct;94(4):279-86 
Focal neurologic deficits in infective endocarditis and other septic diseases.
Bitsch A, Nau R, Hilgers RA, Verheggen R, Werner G, Prange HW
Department of Neurology, Georg-August University Gottingen, Germany.

INTRODUCTION: Focal neurologic deficits in sepsis frequently result from
parenchymal lesions due to cerebral embolism. The aim of this study was to
characterize clinical, laboratory and radiologic patterns of those patients.
PATIENTS AND METHODS: Medical records of 30 patients with focal neurologic
symptoms during sepsis were analyzed retrospectively. RESULTS: 24 patients (22
with infective endocarditis) had ischemic stroke. Cerebrospinal fluid (CSF)
analyses revealed inflammation in 11 of 12 patients. Patients who died (11/24)
suffered more frequently from secondary intracerebral hemorrhage (p = 0.0031),
which was significantly associated with intravenous high-dose anticoagulation
(p = 0.0059). Six patients had slowly progressive focal neurologic deficits
without evidence for stroke. All showed CSF inflammation and three developed
multiple cerebral abscesses. CONCLUSIONS: There are two distinctive groups of
patients with focal neurologic deficits during sepsis. One presents with stroke
and CNS inflammation (septic embolic focal encephalitis). The other group
develops slowly progressive focal neurologic deficits and sometimes multiple
cerebral abscesses (septic metastatic focal encephalitis).
PMID: 8937541, UI: 97091875

1b. Intern Med 1995 Jun;34(6):554-8 
Magnetic resonance imaging of multiple brain abscesses of the bilateral basal
ganglia.
Nagase T, Wada S, Nakamura R, Morisako T, Kamakura K, Kugai N, Yamamoto M,
Tsuchiya K, Nagata N
Third Department of Internal Medicine, National Defense Medical College,
Tokorozawa.

A 64-year-old woman developed multiple brain abscesses of the basal ganglia
associated with Klebsiella pneumoniae septicemia. Magnetic resonance (MR)
images showed three different stages of the brain abscesses. The images of
early cerebritis of this site mimicked lacunar infarctions or dilated
Virchow-Robin spaces. The differentiation of the brain abscess from lacunae and
dilated Virchow-Robin spaces is discussed, together with the evolution of the
brain abscesses on MR images.
PMID: 7549142, UI: 96012387


1c. Infection 1994 May-Jun;22(3):210-2 
Ventriculitis caused by Klebsiella pneumoniae successfully treated with
pefloxacin in a neonate.
Linder N, Dagan R, Kuint J, Keler N, Keren G, Reichman B
Dept. of Neonatology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School
of Medicine, Tel Aviv, Israel.

Pefloxacin was applied to a newborn suffering from ventriculitis caused by
Klebsiella pneumoniae after failure of routine antibiotics. Treatment was
successful. Blood and CSF levels were high, thus documenting good CSF
penetration. In addition to this case report, a review of the literature
regarding seven neonates with CNS infection treated with fluoroquinolones and
from whom CSF levels were obtained, is presented. In conclusion, due to their
excellent activity against gram-negative microorganisms, fluoroquinolones may
be considered in the treatment of neonatal CNS infections if the pathogen is
resistant to routinely used antibiotics. Only limited experience is available
with fluoroquinolones in pediatric patients given their potential for cartilage
toxicity in young animals.
Publication Types:  Review  Review of reported cases
PMID: 7927820, UI: 95012763


1d. J Pediatr 1993 Jan;122(1):15-21 
Gram-negative enteric bacillary meningitis: a twenty-one-year experience.
Unhanand M, Mustafa MM, McCracken GH Jr, Nelson JD
Department of Pediatrics, University of Texas Southwestern Medical Center,
Dallas.

We reviewed our experience with gram-negative enteric bacillary meningitis in
neonates and infants from 1969 through 1989. Ninety-eight patients were
identified. Their ages were from 1 day to 2 years with a median of 10 days. In
25 patients (26%), predisposing factors were identified, the most common of
which were neural tube defects and urinary tract anomalies. The causative
agents were Escherichia coli (53%), Klebsiella-Enterobacter species (16%),
Citrobacter diversus (9%), Salmonella species (9%), Proteus mirabilis (4%),
Serratia marcescens (3%), Bacteroides fragilis (3%), and Aeromonas species
(2%). At the time of diagnosis, Gram-stained smears of cerebrospinal fluid
revealed gram-negative bacilli in 61% of patients. The causative organism was
cultured from blood obtained from 55% of patients, and 21% had positive urine
culture results. The cerebrospinal fluid leukocyte counts ranged from 0 to
80,600 cells/mm3, and the cerebrospinal fluid/serum glucose concentration ratio
was less than 0.5 in 72% of patients. Antimicrobial regimens varied greatly.
After initiation of antibiotic therapy, an average of 3 days was needed for
eradication of bacteria from cerebrospinal fluid. The case-fatality rate was
17%, and 61% of survivors had long-term sequelae that included seizure
disorders, hydrocephalus, physical disability, developmental delay, and hearing
loss.
PMID: 8419603, UI: 93124271



1e. AJNR Am J Neuroradiol 1994 Apr;15(4):763-5 
Subcortical hemorrhage in disseminated intravascular coagulation associated
with sepsis.
Wijdicks EF, Silbert PL, Jack CR, Parisi JE
Department of Neurology, Mayo Clinic, Rochester, MN 55905.

Cranial CT features of two patients with intracerebral hemorrhages in the
setting of sepsis and disseminated intravascular coagulation are reported.
Multiple predominantly subcortical hemorrhages were seen. This pattern of
cerebral hemorrhage should raise suspicion of disseminated intravascular
coagulation as an underlying cause.
PMID: 8010280, UI: 94279636


1f. Childs Nerv Syst 1992 Aug;8(5):279-80 
Brain abscess in infants.
Krajewski R, Stelmasiak Z
Salahuddin University Hospital, Tripoli, Libya.

Brain abscesses are rare in infants and their clinical presentation is specific
for this age group. Seven cases of brain abscess in infants aged 2-11 months
are reported. The underlying cause was meningitis in four, sepsis in two, and
unknown in one. Gram-negative organisms were cultured in 6 patients. The
abscess size was 5 cm or more in five cases; in four there were multiple
lesions. Two abscesses were aspirated and irrigated; four particularly large
lesions were drained and repeatedly aspirated and irrigated. One craniotomy was
done. There were two deaths, one in the postoperative period and the other 6
months after discharge. Follow-up information is available for four children,
showing a good result in only one of them. Formation of an abscess should be
diagnosed early, and close ultrasound monitoring or CT scanning in infants with
bacterial meningitis and sepsis is essential. The prognosis in cases in which
large/multiple abscesses develop is poor.
PMID: 1394267, UI: 93008052


2. Otolaryngol Head Neck Surg 1998 Oct;119(4):357-60 
Sinusitis in neurologically impaired children.
Brook I, Shah K
Department of Pediatrics, Georgetown University, Washington, DC, USA.

The microbiologic features of infected sinus aspirates in nine children with
neurologic impairment were studied. Anaerobic bacteria, always mixed with
aerobic and facultative bacteria, were isolated in 6 (67%) aspirates and
aerobic bacteria only in 3 (33%). There were 24 bacterial isolates, 12 aerobic
or facultative and 12 anaerobic. The predominant aerobic isolates were
Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus (2 each) and
Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae, Moraxella
catarrhalis, and Streptococcus pneumoniae (1 each). The predominant anaerobes
were Prevotella sp. (5), Peptostreptococcus sp. (4), Fusobacterium nucleatum
(2), and Bacteroides fragilis (1). Beta-lactamase-producing bacteria were
isolated from 8 (89%) patients. Organisms similar to those recovered from the
sinuses were also isolated from tracheostomy site and gastrostomy wound
aspirates in five of seven instances. This study demonstrates the uniqueness of
the microbiologic features of sinusitis in neurologically impaired children, in
which, in addition to the organisms known to cause infection in children
without neurologic impairment, facultative and anaerobic gram-negative
organisms that can colonize other body sites are predominant.
PMID: 9781990, UI: 98453251


3. J Am Vet Med Assoc 1996 Jan 15;208(2):243-7 
Hepatic abscesses in dogs: 14 cases (1982-1994).
Farrar ET, Washabau RJ, Saunders HM
Department of Clinical Studies, School of Veterinary Medicine, University of
Pennsylvania, Philadelphia 19104-6010, USA.

OBJECTIVES--To determine typical clinical signs and clinicopathologic findings
in dogs with hepatic abscesses, to assess outcome of treatment, and to evaluate
the role that abdominal ultrasonography has in the diagnosis of hepatic
abscesses in dogs and in monitoring response to treatment.
DESIGN--Retrospective case series. ANIMALS--14 dogs with hepatic abscesses.
RESULTS--Anorexia and lethargy were the most common historical complaints,
followed by vomiting and diarrhea. Physical abnormalities included fever,
dehydration, signs of abdominal pain, hepatomegaly, and mucosal bleeding.
Hematologic abnormalities included leukocytosis with neutrophilia, mild to
moderate thrombocytopenia, and mild anemia. Serum biochemical abnormalities
included high alkaline phosphatase and alanine aminotransferase activities and
high bilirubin concentration; hypoalbuminemia and prolonged coagulation values
were also reported. Abdominal radiography revealed hepatomegaly, poor abdominal
detail, a hepatic mass, or splenomegaly in 9 dogs. Thoracic radiography
revealed alveolar consolidation or mixed bronchial/interstitial pulmonary
patterns in 6 dogs. Hypoechoic, heteroechoic, or hyperechoic masses were
identified in all dogs in which ultrasonography was performed. Escherichia
coli, Clostridium sp, Klebsiella pneumoniae, Enterococcus sp, Staphylococcus
epidermidis, and S intermedius were the most common bacteria isolated from
hepatic abscesses. Concurrent infections were identified in the biliary tract,
spleen, blood, endocardium, lung, prostate gland, peritoneum, lymph nodes,
salivary gland, or brain of several dogs. Seven dogs died or were euthanatized
before definitive treatment could be initiated. One dog was successfully
treated with antibiotics and was alive 12 months after medical treatment. Six
dogs were treated surgically (ie, full or partial liver lobectomy, drainage,
abdominal lavage) and medically (ie, antibiotic administration). Five of these
dogs survived and were alive 12 months after surgery. Ultrasonography was used
to monitor response to treatment in several dogs. CLINICAL
IMPLICATIONS--Hepatic abscesses are rare in dogs, but the clinical signs and
clinicopathologic findings are similar to other inflammatory hepatic disease.
Ultrasonography revealed abnormalities in all animals in which imaging studies
were performed, and was successfully used to monitor response to treatment in
several dogs. Medical and surgical treatments were used successfully to treat
hepatic abscesses in dogs.
PMID: 8567382, UI: 96134131

4. Arch Intern Med 1991 Aug;151(8):1557-9 
Septic metastatic lesions of pyogenic liver abscess. Their association with
Klebsiella pneumoniae bacteremia in diabetic patients.
Cheng DL, Liu YC, Yen MY, Liu CY, Wang RS
Department of Medicine, Veterans General Hospital, Taipei, Taiwan, Republic of
China.

Septic metastatic endophthalmitis from Klebsiella pneumoniae liver abscess,
first reported in seven cases treated at the Veterans General Hospital, Taipei,
Taiwan, between 1981 and 1985, was seen in six similar cases at the same
hospital in the subsequent 2 years. We conducted a retrospective search for
factors that might be associated with these complications of pyogenic liver
abscess. A total of 23 cases with septic metastatic lesions from pyogenic liver
abscess were found between 1981 and 1987, and 164 cases of pyogenic liver
abscess without septic metastatic lesions were identified as a comparison
group. Klebsiella pneumoniae liver abscess, bacteremia, and the underlying
diabetes mellitus were significantly more common in the study group than in the
comparison group. Of the 23 patients with septic metastatic lesions, there were
14 cases (60.8%) of endophthalmitis or uveitis, 10 cases (43.4%) of pulmonary
abscess and/or emboli, six cases (26.0%) of brain abscess and/or purulent
meningitis, five cases (21.7%) of bacteriuria and/or prostate abscess, two
cases (8.6%) of osteomyelitis and/or pyogenic arthritis, and one case (4.3%) of
psoas abscess.
PMID: 1872659, UI: 91336796


5a. AJR Am J Roentgenol 1980 Aug;135(2):263-7 
CT of central nervous system infections in immunocompromised patients.
Enzmann DR, Brant-Zawadzki M, Britt RH

The computed tomographic (CT) scan appearance of parenchymal central nervous
system (CNS) infection in 12 immunosuppressed patients was unlike that of the
usual bacterial abscess in immunologically intact hosts. The lesions were
poorly circumscribed and of low density. Contrast enhancement was minimal and
did not assume a "ring" configuration. These CT scan findings heralded a poor
prognosis. Compared to the neuropathologic findings, the CT scan generally
underestimated the extent of involvement. Three other compromised patients were
better able to localize the infection. This successful defense was manifested
on their CT scans as the more typical "ring" pattern of contrast enhancement.
Patients with this CT scan appearance of their CNS infection had a better
prognosis.
PMID: 6773324, UI: 80262711


5b. Pediatr Infect Dis J 1990 Nov;9(11):810-4 
Cefotaxime and aminoglycoside treatment of meningitis caused by gram-negative
enteric organisms.
Kaplan SL, Patrick CC
Myers Black Section of Pediatrics Infectious Diseases, Department of
Pediatrics, Baylor College of Medicine, Houston, TX.

We reviewed cases of Gram-negative enteric bacillary meningitis in infants and
children treated with cefotaxime at Texas Children's Hospital from January,
1984, through June, 1989. Seventeen of 20 children had an underlying condition
predisposing to the development of meningitis. The etiologic organisms in these
20 children (2 days to 12 years old; median, 12 days old) were Klebsiella sp,
9; Escherichia coli, 4; Enterobacter cloacae, 3; Citrobacter diversus, 2;
other, 2. With the exception of one isolate of Acinetobacter, all isolates were
susceptible to cefotaxime. In addition to cefotaxime 17 children received an
aminoglycoside intravenously. Children with meningitis caused by Klebsiella sp.
or non-Klebsiella organisms received cefotaxime for 31 +/- 14 and 37 +/- 17
days, respectively. Aminoglycosides were administered for 16 +/- 10 days in
both groups. Five children in each group also received intraventricular doses
(1 to 25) of an aminoglycoside (9) or colistimethate (1). The mean durations of
positive lumbar, ventricular cerebrospinal fluid or brain abscess cultures were
5.8 +/- 4.7 and 7.2 +/- 5.0 days after start of therapy in the Klebsiella and
non-Klebsiella meningitis patients, respectively. Only three children were
normal at the time of discharge or follow-up. Gram-negative enteric meningitis
remains difficult to treat despite the excellent in vitro activity of
cefotaxime against Gram-negative enterics, in part as a result of the
predisposing conditions resulting in the development of this infection.
PMID: 2263430, UI: 91088226


6. Pediatr Nephrol 1998 Oct;12(8):658-9 
Hyperammonaemia due to Klebsiella infection in a neuropathic bladder.
Cheang HK, Rangecroft L, Plant ND, Morris AA
Department of Child Health, Royal Victoria Infirmary, Newcastle upon Tyne, UK.

A boy with a neuropathic bladder and a single hydronephrotic kidney developed
hyperammonaemic encephalopathy during a urinary tract infection with Klebsiella
oxytoca. Although particularly associated with Proteus infections and prune
belly syndrome, hyperammonaemia can complicate infection with any
urease-producing bacteria if there is urinary stasis.
PMID: 9811390, UI: 99027529


7. Surgery 1998 Aug;124(2):418-28 
Bacterially preexposed T cells impair bacterial elimination by non-Th1/Th2 cell
mechanisms in a model of intra-abdominal infection.
Gleason TG, Sawyer RG, Pruett TL
Surgical Infectious Disease Laboratory, University of Virginia, Charlottesville
22908, USA.

BACKGROUND: Escherichia coli preexposure in mice results in impaired
elimination of subsequent intra-abdominal infections by a CD+4 T cell-dependent
process. Certain gram-negative infections have been shown to induce
T-helper-(Th)2 type CD4+ T-cell differentiation, which correlates with impaired
elimination of infection and death. We hypothesized that E coli preexposure
impairs subsequent bacterial elimination as a consequence of Th2
differentiation and that interleukin-12 (IL-12) treatment could reverse this
differentiation and minimize the effects of E coli preexposure. METHODS: After
preexposure to E coli or other species, BALB/c mice or interferon-gamma
(INF-gamma)-deficient mice, treated with or without IL-12, were given a
standard intra-abdominal infection (E coli, Bacteroides fragilis, and
adjuvant). Cohorts were killed for abscess quantification, in vitro T-cell
proliferative responsiveness, and cytokine secretory profiles. Splenic
lymphocytes preexposed in vivo to other types of bacteria were transferred to
naive mice before intra-abdominal infection to determine whether preexposure,
eliciting the lymphocyte-dependent response, was species specific. RESULTS: E
coli preexposure alone caused no Th1 or Th2 shift; increased the proliferative
responses of T cells; and, in combination with IL-12 therapy, caused markedly
decreased IL-2 and IL-4 responses and an increased IFN-gamma response. IL-12
therapy did not change the response to intra-abdominal infection despite its
ability to cause marked Th1 polarization. IFN-gamma-deficient mice responded to
E coli preexposure no differently than did wild-type mice. Transfer of
lymphocytes preexposed to Pseudomonas aeruginosa, Klebsiella pneumoniae, and
hemolytic E coli but not other types of nosocomial pathogens caused the
development of more abscesses just as transfer of E coli preexposed lymphocytes
had. CONCLUSIONS: CD4+ T cells responsive to E coli preexposure regulate
subsequent intra-abdominal abscess formation by a mechanism not explained by
the Th1/Th2 paradigm. Preexposure to hemolytic E coli and other
Enterobacteriaceae alters responses to intra-abdominal infection.
PMID: 9706167, UI: 98371424


8. Arch Neurol 1981 Jan;38(1):43-5 
Effect of CSF on bacterial growth.
Agbayani MM, Braun J, Chang CT, Glass L, Evans HE

The growth patterns of five potentially pathogenic bacteria (Staphylococcus
aureus, Escherichia coli, Listeria monocytogenes, group B beta-hemolytic
streptococcus, and Klebsiella pneumoniae) and a commonly encountered,
nonpathogenic microorganism (S epidermidis) were compared using CSF, trypticase
soy broth (TSB), and a phosphate buffer. Each grew less in CSF than in TSB.
Escherichia coli was least affected with a median difference of 2 logarithms
between CSF and TSB at 24 hours of growth, whereas S epidermidis was markedly
inhibited, with a median difference of 6.85 logarithms. The differences among
the remaining four organisms ranged from 3.86 to 5.94 logarithms, all
significantly greater than that for E. coli. Similar results were obtained at
48 hours of growth. The non-support of bacterial growth by CSF may constitute
a host defense mechanism. The basis of these observations may be the presence
of inhibitors or the absence of nutrients required for bacterial growth in the
CSF.
PMID: 6779784, UI: 81109037

9a. Infect Immun 1997 Apr;65(4):1546-9 
Binding of the type 3 fimbriae of Klebsiella pneumoniae to human endothelial
and urinary bladder cells.
Tarkkanen AM, Virkola R, Clegg S, Korhonen TK
Department of Biosciences, FIN-00014 University of Helsinki, Finland.

Binding of the two identified type 3 fimbrial variants of Klebsiella pneumoniae
to human endothelial EA-hy926 and bladder T24 cells was assessed. The
recombinant Escherichia coli strain LE392(pFK12), expressing plasmid-encoded
type 3 fimbriae of K. pneumoniae, adhered to both cell lines, and the fimbriae
purified from the strain bound to both cell lines in a dose-dependent manner.
Adhesiveness to both cell lines of chromosomally encoded type 3 fimbriae from
K. pneumoniae IApc35 was lower. No binding was detected with type 1 fimbriae of
K. pneumoniae. Both type 3 fimbrial variants exhibited a significantly lower
affinity for the cell lines than did S fimbriae of meningitis-associated E.
coli.
PMID: 9119502, UI: 97230338

9b. Infect Immun 1995 Oct;63(10):4046-53 
Activation of human endothelial cells by viable or heat-killed gram-negative
bacteria requires soluble CD14.
Noel RF Jr, Sato TT, Mendez C, Johnson MC, Pohlman TH
Department of Surgery, University of Washington School of Medicine, Seattle
98104, USA.

In response to bacterial lipopolysaccharides (LPS; endotoxin), endothelial
cells are converted to an activation phenotype expressing both proinflammatory
and procoagulant properties that include the induction of leukocyte adhesion
molecules and tissue factor expression. LPS-induced endothelial cell activation
requires a soluble form of the monocyte LPS receptor, sCD14. We evaluated the
capacity of multiple strains of gram-negative and gram-positive bacteria to
induce endothelial E-selectin and tissue factor expression through
sCD14-dependent pathways with cultured human umbilical vein endothelial cells
(HUVE). Both viable and heat-killed gram-negative bacteria (Bacteroides
fragilis, Enterobacter cloacae, Haemophilus influenzae, and Klebsiella
pneumoniae) but not viable or heat-killed gram-positive bacteria
(Staphylococcus aureus, Enterococcus faecalis, and Streptococcus pneumoniae)
induced prominent E-selectin surface expression detected by enzyme-linked
immunosorbent assay. Tissue factor activity on HUVE, indicated by factor X
activation, was induced in response to gram-negative bacteria but not in
response to gram-positive bacteria. Gram-negative bacteria induced
transcriptional activation in HUVE, indicated by the appearance of
E-selectin-specific mRNA and by the demonstration of activation of NF-kappa B,
a trans-activating factor necessary for E-selectin and tissue factor gene
transcription. In contrast, neither E-selectin mRNA nor activation of NF-kappa
B was detected in HUVE treated with gram-positive bacteria. Endothelial cell
activation by gram-negative bacteria in each of these assays was inhibited with
a monoclonal antibody (60bd) against CD14. Furthermore, CHO-K1 cells,
transfected with human recombinant CD14, responded to all strains of
gram-negative bacteria (viable or heat killed), indicated by CHO-K1 NF-kappa B
activation. We conclude that gram-negative bacteria induce endothelial cell
activation through a common sCD14-dependent pathway.
PMID: 7558318, UI: 96009765

10. A preliminary analysis of bbb infections and sequalae therefrom
HTTP://www.jorsm.com/~binstock/bbb-inf.htm