Метотрексатиндуцированное поражение легких у больной ревматоидным артритом - Журнал Терапевтический архив №3 Вопросы пульмонологии 2021
Метотрексатиндуцированное поражение легких у больной ревматоидным артритом
Пономарева Л.А., Гурова Д.В., Попова Е.Н., Чеботарева Н.В., Бондаренко И.Б., Моисеев С.В. Метотрексатиндуцированное поражение легких у больной ревматоидным артритом. Терапевтический архив. 2021; 93 (3): 295–299. DOI: 10.26442/00403660.2021.03.200656
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Аннотация
Представлено клиническое наблюдение метотрексатиндуцированного интерстициального поражения легких у пациентки с манифестирующим ревматоидным артритом (РА). Обсуждается диагностическая настороженность в отношении лекарственно-обусловленного легочного повреждения, на основе сопоставления клинико-инструментальных данных представлена дифференциальная диагностика между пневмонитом, вызванным метотрексатом у больной РА на фоне базисной терапии препаратом, и интерстициальной болезнью легких, ассоциированной с РА. Основным условием благоприятного прогноза при всех вариантах лекарственных поражений легких является отмена этиологического фактора, что продемонстрировано в данном клиническом случае.
Ключевые слова: метотрексат, ревматоидный артрит, легочный фиброз, лекарственно-индуцированные поражения легких
Keywords: methotrexate, rheumatoid arthritis, pulmonary fibrosis, drug-induced lung disease
Ключевые слова: метотрексат, ревматоидный артрит, легочный фиброз, лекарственно-индуцированные поражения легких
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Keywords: methotrexate, rheumatoid arthritis, pulmonary fibrosis, drug-induced lung disease
Список литературы
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8. Chansakul T, Dellaripa PF, Doyle TJ, Madan R. Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications. Eur J Radiol. 2015;84(10):1981-91.
doi: 10.1016/j.ejrad.2015.07.008
9. Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum. 2014;43(5):613-26. doi: 10.1016/j.semarthrit.2013.09.005
10. Alarcón GS, Kremer JM, Macaluso M, et al. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. A multicenter, case-control study. Methotrexate-Lung Study Group. Ann Intern Med. 1997;127(5): 356-64.
doi: 10.7326/0003-4819-127-5-199709010-00003
11. Atzeni F, Boiardi L, Sallì S, et al. Lung involvement and drug-induced lung disease in patients with rheumatoid arthritis. Expert Rev Clin Immunol. 2013;9(7):649-57. doi: 10.1586/1744666X.2013.811173
12. Pavy S, Constantin A, Pham T, et al. Methotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006;73(4):388-95. doi: 10.1016/j.jbspin.2006.01.007
13. Conway R, Low C, Coughlan RJ, et al. Methotrexate and lung disease in rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66(4):803-12. doi: 10.1002/art.38322
14. Salehi M, Miller R, Khaing M. Methotrexate-induced Hypersensitivity Pneumonitis appearing after 30 years of use: a case report. J Med Case Rep. 2017;11(1):174. doi: 10.1186/s13256-017-1333-0
15. Yamakawa H, Yoshida M, Takagi M, Kuwano K. Late-onset methotrexate-induced pneumonitis with neutrophilia in bronchoalveolar lavage fluid. BMJ Case Rep. 2014;2014:bcr2014206123. doi: 10.1136/bcr-2014-206123
16. Dong H, Julien PJ, Demoruelle MK, et al. Interstitial lung abnormalities in patients with early rheumatoid arthritis: A pilot study evaluating prevalence and progression. Eur J Rheumatol. 2018;6(4):193-8. doi: 10.5152/eurjrheum.2019.19044
17. Furukawa H, Oka S, Shimada K; Rheumatoid Arthritis-Interstitial Lung Disease Study Consortium, Tsuchiya N, Tohma S. HLA-A*31:01 and methotrexate-induced interstitial lung disease in Japanese rheumatoid arthritis patients: a multidrug hypersensitivity marker? Ann Rheum Dis. 2013;72(1):153-5. doi: 10.1136/annrheumdis-2012-201944
18. Bluett J, Owen SA, Massey J, et al. HLA-A 31:01 is not associated with the development of methotrexate pneumonitis in the UK population: results from a genome-wide association study. Ann Rheum Dis. 2017;76(12):e51. doi: 10.1136/annrheumdis-2017-211512
19. Jakubovic BD, Donovan A, Webster PM, Shear NH. Methotrexate-induced pulmonary toxicity. Can Respir J. 2013;20(3):153-5. doi: 10.1155/2013/527912
20. Ohbayashi M, Suzuki M, Yashiro Y, et al. Induction of pulmonary fibrosis by methotrexate treatment in mice lung in vivo and in vitro. J Toxicol Sci. 2010;35(5):653-61. doi: 10.2131/jts.35.653
21. Fragoulis GE, Nikiphorou E, Larsen J, et al. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Front Med (Lausanne). 2019;6:238. doi: 10.3389/fmed.2019.00238
22. D’Elia T. Methotrexate-induced pneumonitis: heterogeneity of bronchoalveolar lavage and differences between cancer and rheumatoid arthritis. Inflamm Allergy Drug Targets. 2014;13(1):25-33. doi: 10.2174/1871528112666131230013059
23. Chikura B, Sathi N, Lane S, Dawson JK. Variation of immunological response in methotrexate-induced pneumonitis. Rheumatology (Oxford). 2008;47(11):1647-50. doi: 10.1093/rheumatology/ken356
24. Tokunaga T. A Case of Drug-Induced Pneumonitis Associated With Chinese Herbal Drugs and Valsartan. Nihon Kokyuki Gakkai Zasshi. 2005;43(7):406-11. PMID: 16050466
25. Zitnik RJ, Cooper JA Jr. Pulmonary disease due to antirheumatic agents. Clin Chest Med. 1990;11(1):139-50. PMID: 1969788
2. Thickett DR, Millar AB. Drug-induced antisynthetase syndrome. Postgrad Med J. 1997;73(857):165-6. doi: 10.1136/pgmj.73.857.165
3. Lengyel C, Boros I, Várkonyi T, et al. Amiodarone-induced pulmonary fibrosis. Orv Hetil. 1996;137(32):1759-62.
4. Fauroux B, Clément A, Tournier G. Pulmonary toxicity of drugs and thoracic irradiation in children. Rev Mal Respir. 1996;13(3):235-42.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update [published online ahead of print, 2020 Jan 22]. Ann Rheum Dis. 2020; annrheumdis-2019-216655. doi: 10.1136/annrheumdis-2019-216655
6. Weinblatt ME. Methotrexate in rheumatoid arthritis: a quarter century of development. Trans Am Clin Climatol Assoc. 2013;124:16-25.
7. Doyle TJ, Dellaripa PF. Lung Manifestations in the Rheumatic Diseases. Chest. 2017;152(6):1283-95. doi: 10.1016/j.chest.2017.05.015
8. Chansakul T, Dellaripa PF, Doyle TJ, Madan R. Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications. Eur J Radiol. 2015;84(10):1981-91. doi: 10.1016/j.ejrad.2015.07.008
9. Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum. 2014;43(5):613-26. doi: 10.1016/j.semarthrit.2013.09.005
10. Alarcón GS, Kremer JM, Macaluso M, et al. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. A multicenter, case-control study. Methotrexate-Lung Study Group. Ann Intern Med. 1997;127(5): 356-64.
doi: 10.7326/0003-4819-127-5-199709010-00003
11. Atzeni F, Boiardi L, Sallì S, et al. Lung involvement and drug-induced lung disease in patients with rheumatoid arthritis. Expert Rev Clin Immunol. 2013;9(7):649-57. doi: 10.1586/1744666X.2013.811173
12. Pavy S, Constantin A, Pham T, et al. Methotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006;73(4):388-95. doi: 10.1016/j.jbspin.2006.01.007
13. Conway R, Low C, Coughlan RJ, et al. Methotrexate and lung disease in rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66(4):803-12. doi: 10.1002/art.38322
14. Salehi M, Miller R, Khaing M. Methotrexate-induced Hypersensitivity Pneumonitis appearing after 30 years of use: a case report. J Med Case Rep. 2017;11(1):174. doi: 10.1186/s13256-017-1333-0
15. Yamakawa H, Yoshida M, Takagi M, Kuwano K. Late-onset methotrexate-induced pneumonitis with neutrophilia in bronchoalveolar lavage fluid. BMJ Case Rep. 2014;2014:bcr2014206123. doi: 10.1136/bcr-2014-206123
16. Dong H, Julien PJ, Demoruelle MK, et al. Interstitial lung abnormalities in patients with early rheumatoid arthritis: A pilot study evaluating prevalence and progression. Eur J Rheumatol. 2018;6(4):193-8. doi: 10.5152/eurjrheum.2019.19044
17. Furukawa H, Oka S, Shimada K; Rheumatoid Arthritis-Interstitial Lung Disease Study Consortium, Tsuchiya N, Tohma S. HLA-A*31:01 and methotrexate-induced interstitial lung disease in Japanese rheumatoid arthritis patients: a multidrug hypersensitivity marker? Ann Rheum Dis. 2013;72(1):153-5. doi: 10.1136/annrheumdis-2012-201944
18. Bluett J, Owen SA, Massey J, et al. HLA-A 31:01 is not associated with the development of methotrexate pneumonitis in the UK population: results from a genome-wide association study. Ann Rheum Dis. 2017;76(12):e51. doi: 10.1136/annrheumdis-2017-211512
19. Jakubovic BD, Donovan A, Webster PM, Shear NH. Methotrexate-induced pulmonary toxicity. Can Respir J. 2013;20(3):153-5. doi: 10.1155/2013/527912
20. Ohbayashi M, Suzuki M, Yashiro Y, et al. Induction of pulmonary fibrosis by methotrexate treatment in mice lung in vivo and in vitro. J Toxicol Sci. 2010;35(5):653-61. doi: 10.2131/jts.35.653
21. Fragoulis GE, Nikiphorou E, Larsen J, et al. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Front Med (Lausanne). 2019;6:238. doi: 10.3389/fmed.2019.00238
22. D’Elia T. Methotrexate-induced pneumonitis: heterogeneity of bronchoalveolar lavage and differences between cancer and rheumatoid arthritis. Inflamm Allergy Drug Targets. 2014;13(1):25-33. doi: 10.2174/1871528112666131230013059
23. Chikura B, Sathi N, Lane S, Dawson JK. Variation of immunological response in methotrexate-induced pneumonitis. Rheumatology (Oxford). 2008;47(11):1647-50. doi: 10.1093/rheumatology/ken356
24. Tokunaga T. A Case of Drug-Induced Pneumonitis Associated With Chinese Herbal Drugs and Valsartan. Nihon Kokyuki Gakkai Zasshi. 2005;43(7):406-11. PMID: 16050466
25. Zitnik RJ, Cooper JA Jr. Pulmonary disease due to antirheumatic agents. Clin Chest Med. 1990;11(1):139-50. PMID: 1969788
2. Thickett DR, Millar AB. Drug-induced antisynthetase syndrome. Postgrad Med J. 1997;73(857):165-6. doi: 10.1136/pgmj.73.857.165
3. Lengyel C, Boros I, Várkonyi T, et al. Amiodarone-induced pulmonary fibrosis. Orv Hetil. 1996;137(32):1759-62.
4. Fauroux B, Clément A, Tournier G. Pulmonary toxicity of drugs and thoracic irradiation in children. Rev Mal Respir. 1996;13(3):235-42.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update [published online ahead of print, 2020 Jan 22]. Ann Rheum Dis. 2020; annrheumdis-2019-216655. doi: 10.1136/annrheumdis-2019-216655
6. Weinblatt ME. Methotrexate in rheumatoid arthritis: a quarter century of development. Trans Am Clin Climatol Assoc. 2013;124:16-25.
7. Doyle TJ, Dellaripa PF. Lung Manifestations in the Rheumatic Diseases. Chest. 2017;152(6):1283-95. doi: 10.1016/j.chest.2017.05.015
8. Chansakul T, Dellaripa PF, Doyle TJ, Madan R. Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications. Eur J Radiol. 2015;84(10):1981-91.
doi: 10.1016/j.ejrad.2015.07.008
9. Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum. 2014;43(5):613-26. doi: 10.1016/j.semarthrit.2013.09.005
10. Alarcón GS, Kremer JM, Macaluso M, et al. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. A multicenter, case-control study. Methotrexate-Lung Study Group. Ann Intern Med. 1997;127(5): 356-64.
doi: 10.7326/0003-4819-127-5-199709010-00003
11. Atzeni F, Boiardi L, Sallì S, et al. Lung involvement and drug-induced lung disease in patients with rheumatoid arthritis. Expert Rev Clin Immunol. 2013;9(7):649-57. doi: 10.1586/1744666X.2013.811173
12. Pavy S, Constantin A, Pham T, et al. Methotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006;73(4):388-95. doi: 10.1016/j.jbspin.2006.01.007
13. Conway R, Low C, Coughlan RJ, et al. Methotrexate and lung disease in rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66(4):803-12. doi: 10.1002/art.38322
14. Salehi M, Miller R, Khaing M. Methotrexate-induced Hypersensitivity Pneumonitis appearing after 30 years of use: a case report. J Med Case Rep. 2017;11(1):174. doi: 10.1186/s13256-017-1333-0
15. Yamakawa H, Yoshida M, Takagi M, Kuwano K. Late-onset methotrexate-induced pneumonitis with neutrophilia in bronchoalveolar lavage fluid. BMJ Case Rep. 2014;2014:bcr2014206123. doi: 10.1136/bcr-2014-206123
16. Dong H, Julien PJ, Demoruelle MK, et al. Interstitial lung abnormalities in patients with early rheumatoid arthritis: A pilot study evaluating prevalence and progression. Eur J Rheumatol. 2018;6(4):193-8. doi: 10.5152/eurjrheum.2019.19044
17. Furukawa H, Oka S, Shimada K; Rheumatoid Arthritis-Interstitial Lung Disease Study Consortium, Tsuchiya N, Tohma S. HLA-A*31:01 and methotrexate-induced interstitial lung disease in Japanese rheumatoid arthritis patients: a multidrug hypersensitivity marker? Ann Rheum Dis. 2013;72(1):153-5. doi: 10.1136/annrheumdis-2012-201944
18. Bluett J, Owen SA, Massey J, et al. HLA-A 31:01 is not associated with the development of methotrexate pneumonitis in the UK population: results from a genome-wide association study. Ann Rheum Dis. 2017;76(12):e51. doi: 10.1136/annrheumdis-2017-211512
19. Jakubovic BD, Donovan A, Webster PM, Shear NH. Methotrexate-induced pulmonary toxicity. Can Respir J. 2013;20(3):153-5. doi: 10.1155/2013/527912
20. Ohbayashi M, Suzuki M, Yashiro Y, et al. Induction of pulmonary fibrosis by methotrexate treatment in mice lung in vivo and in vitro. J Toxicol Sci. 2010;35(5):653-61. doi: 10.2131/jts.35.653
21. Fragoulis GE, Nikiphorou E, Larsen J, et al. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Front Med (Lausanne). 2019;6:238. doi: 10.3389/fmed.2019.00238
22. D’Elia T. Methotrexate-induced pneumonitis: heterogeneity of bronchoalveolar lavage and differences between cancer and rheumatoid arthritis. Inflamm Allergy Drug Targets. 2014;13(1):25-33. doi: 10.2174/1871528112666131230013059
23. Chikura B, Sathi N, Lane S, Dawson JK. Variation of immunological response in methotrexate-induced pneumonitis. Rheumatology (Oxford). 2008;47(11):1647-50. doi: 10.1093/rheumatology/ken356
24. Tokunaga T. A Case of Drug-Induced Pneumonitis Associated With Chinese Herbal Drugs and Valsartan. Nihon Kokyuki Gakkai Zasshi. 2005;43(7):406-11. PMID: 16050466
25. Zitnik RJ, Cooper JA Jr. Pulmonary disease due to antirheumatic agents. Clin Chest Med. 1990;11(1):139-50. PMID: 1969788
________________________________________________
2. Thickett DR, Millar AB. Drug-induced antisynthetase syndrome. Postgrad Med J. 1997;73(857):165-6. doi: 10.1136/pgmj.73.857.165
3. Lengyel C, Boros I, Várkonyi T, et al. Amiodarone-induced pulmonary fibrosis. Orv Hetil. 1996;137(32):1759-62.
4. Fauroux B, Clément A, Tournier G. Pulmonary toxicity of drugs and thoracic irradiation in children. Rev Mal Respir. 1996;13(3):235-42.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update [published online ahead of print, 2020 Jan 22]. Ann Rheum Dis. 2020; annrheumdis-2019-216655. doi: 10.1136/annrheumdis-2019-216655
6. Weinblatt ME. Methotrexate in rheumatoid arthritis: a quarter century of development. Trans Am Clin Climatol Assoc. 2013;124:16-25.
7. Doyle TJ, Dellaripa PF. Lung Manifestations in the Rheumatic Diseases. Chest. 2017;152(6):1283-95. doi: 10.1016/j.chest.2017.05.015
8. Chansakul T, Dellaripa PF, Doyle TJ, Madan R. Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications. Eur J Radiol. 2015;84(10):1981-91. doi: 10.1016/j.ejrad.2015.07.008
9. Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum. 2014;43(5):613-26. doi: 10.1016/j.semarthrit.2013.09.005
10. Alarcón GS, Kremer JM, Macaluso M, et al. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. A multicenter, case-control study. Methotrexate-Lung Study Group. Ann Intern Med. 1997;127(5): 356-64.
doi: 10.7326/0003-4819-127-5-199709010-00003
11. Atzeni F, Boiardi L, Sallì S, et al. Lung involvement and drug-induced lung disease in patients with rheumatoid arthritis. Expert Rev Clin Immunol. 2013;9(7):649-57. doi: 10.1586/1744666X.2013.811173
12. Pavy S, Constantin A, Pham T, et al. Methotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006;73(4):388-95. doi: 10.1016/j.jbspin.2006.01.007
13. Conway R, Low C, Coughlan RJ, et al. Methotrexate and lung disease in rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66(4):803-12. doi: 10.1002/art.38322
14. Salehi M, Miller R, Khaing M. Methotrexate-induced Hypersensitivity Pneumonitis appearing after 30 years of use: a case report. J Med Case Rep. 2017;11(1):174. doi: 10.1186/s13256-017-1333-0
15. Yamakawa H, Yoshida M, Takagi M, Kuwano K. Late-onset methotrexate-induced pneumonitis with neutrophilia in bronchoalveolar lavage fluid. BMJ Case Rep. 2014;2014:bcr2014206123. doi: 10.1136/bcr-2014-206123
16. Dong H, Julien PJ, Demoruelle MK, et al. Interstitial lung abnormalities in patients with early rheumatoid arthritis: A pilot study evaluating prevalence and progression. Eur J Rheumatol. 2018;6(4):193-8. doi: 10.5152/eurjrheum.2019.19044
17. Furukawa H, Oka S, Shimada K; Rheumatoid Arthritis-Interstitial Lung Disease Study Consortium, Tsuchiya N, Tohma S. HLA-A*31:01 and methotrexate-induced interstitial lung disease in Japanese rheumatoid arthritis patients: a multidrug hypersensitivity marker? Ann Rheum Dis. 2013;72(1):153-5. doi: 10.1136/annrheumdis-2012-201944
18. Bluett J, Owen SA, Massey J, et al. HLA-A 31:01 is not associated with the development of methotrexate pneumonitis in the UK population: results from a genome-wide association study. Ann Rheum Dis. 2017;76(12):e51. doi: 10.1136/annrheumdis-2017-211512
19. Jakubovic BD, Donovan A, Webster PM, Shear NH. Methotrexate-induced pulmonary toxicity. Can Respir J. 2013;20(3):153-5. doi: 10.1155/2013/527912
20. Ohbayashi M, Suzuki M, Yashiro Y, et al. Induction of pulmonary fibrosis by methotrexate treatment in mice lung in vivo and in vitro. J Toxicol Sci. 2010;35(5):653-61. doi: 10.2131/jts.35.653
21. Fragoulis GE, Nikiphorou E, Larsen J, et al. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Front Med (Lausanne). 2019;6:238. doi: 10.3389/fmed.2019.00238
22. D’Elia T. Methotrexate-induced pneumonitis: heterogeneity of bronchoalveolar lavage and differences between cancer and rheumatoid arthritis. Inflamm Allergy Drug Targets. 2014;13(1):25-33. doi: 10.2174/1871528112666131230013059
23. Chikura B, Sathi N, Lane S, Dawson JK. Variation of immunological response in methotrexate-induced pneumonitis. Rheumatology (Oxford). 2008;47(11):1647-50. doi: 10.1093/rheumatology/ken356
24. Tokunaga T. A Case of Drug-Induced Pneumonitis Associated With Chinese Herbal Drugs and Valsartan. Nihon Kokyuki Gakkai Zasshi. 2005;43(7):406-11. PMID: 16050466
25. Zitnik RJ, Cooper JA Jr. Pulmonary disease due to antirheumatic agents. Clin Chest Med. 1990;11(1):139-50. PMID: 1969788
Авторы
Л.А. Пономарева, Д.В. Гурова, Е.Н. Попова*, Н.В. Чеботарева, И.Б. Бондаренко, С.В. Моисеев
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*ela12@yandex.ru
Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*ela12@yandex.ru
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*ela12@yandex.ru
________________________________________________
Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*ela12@yandex.ru
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