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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 61  |  Issue : 3  |  Page : 345-349
Incidentally detected asymptomatic hepatitis C virus infection with significant fibrosis: Possible impacts on management


1 Department of Pathology, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
2 Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

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Date of Web Publication13-Jul-2018
 

   Abstract 


Background and Aims: Liver biopsy may be considered in patients with hepatitis C virus (HCV) infection to assess the severity of liver injury and stage of fibrosis, thereby guiding therapeutic decisions. In addition, advanced stage also necessitates surveillance for hepatocellular carcinoma. The aim of this study was to assess whether transaminase (alanine transaminase [ALT]) levels and RNA titers correlate with the histological activity index (HAI) and fibrosis (F) stage in asymptomatic patients with incidentally detected HCV (IDHCV). Patients and Methods: Retrospective evaluation of liver biopsies was done in 113 patients with IDHCV, diagnosed during routine screening. Decision of liver biopsy was made on the basis of age, genotype, acceptable clinical, hematological, and biochemical profiles, and willingness of the patients to undergo treatment. Serum ALT levels, HCV RNA titers, and genotypes were correlated with HAI and F stage. Results: Genotyping was done in 77 of the 113 patients, of which genotype 3 was seen in 43 and genotype 1 in 25 patients. A higher fibrosis stage (Ishak's >F2) was noted in 23.8% of the biopsies. Serum ALT showed a significant correlation with the HAI score on liver biopsy (P = 0.01) but not with the stage of fibrosis (P = 0.52). HCV RNA titers did not reveal any correlation with HAI score or fibrosis stage. Conclusion: Serum transaminases and HCV RNA titers are poor predictors of disease severity and fibrosis. Since HCV shows a slow disease progression, higher stage may predict a worse prognosis irrespective of the low viral RNA load. Liver biopsy may help guide therapeutic decisions in IDHCV infection.

Keywords: Fibrosis, hepatitis, hepatitis C virus, histology, liver biopsy

How to cite this article:
Gupta RK, Sakhuja P, Majumdar K, Ali S, Srivastava S, Sachdeva S, Sharma BC, Puri AS. Incidentally detected asymptomatic hepatitis C virus infection with significant fibrosis: Possible impacts on management. Indian J Pathol Microbiol 2018;61:345-9

How to cite this URL:
Gupta RK, Sakhuja P, Majumdar K, Ali S, Srivastava S, Sachdeva S, Sharma BC, Puri AS. Incidentally detected asymptomatic hepatitis C virus infection with significant fibrosis: Possible impacts on management. Indian J Pathol Microbiol [serial online] 2018 [cited 2019 Dec 9];61:345-9. Available from: http://www.ijpmonline.org/text.asp?2018/61/3/345/236602





   Introduction Top


India is mapped into a moderately prevalent zone for hepatitis C virus (HCV) infection with an approximate prevalence of 1.3% among general population.[1] However, many of these patients remain undetected and only around 25% of them are diagnosed, of which only 5% undergo treatment.[2] This is due to the asymptomatic state, chronicity, and slow disease progression of this infection supplemented with a lack of awareness and effective implementation of screening techniques at the community level, especially in developing countries. Many of these patients are incidentally detected through routine health checkup, during pregnancy or screening of voluntary blood donors.

Incidentally detected HCV (IDHCV) infection refers to the clinical situation when in an asymptomatic individual, anti-HCV antibodies test positive in the blood while undergoing a routine health checkup for various reasons including raised transaminases. Subsequently, these patients are advised estimation of aminotransferases and viral load along with the genotyping. The introduction of better tolerable and effective directly acting antivirals has revolutionized the treatment of chronic hepatitis C. Liver biopsy though invasive accurately evaluates the severity of liver injury and stage of fibrosis, thereby guiding therapeutic decisions and predicting prognosis. In addition, advanced stage also necessitates surveillance for hepatocellular carcinoma (HCC). The aim of this study was to analyze whether transaminase (alanine transaminase [ALT]) levels and RNA titers correlate with the histological activity index (HAI) and fibrosis (F) stage in patients with incidentally detected asymptomatic HCV infection (IDHCV). In addition, critical evaluation of the role of liver biopsy in accurate assessment of the spectrum and extent of liver injury was attempted, as a part of the management protocol in these patients.


   Patients and Methods Top


This is a retrospective observational study analyzing 113 consecutive biopsies received from the IDHCV patients who had presented in the liver clinic of gastroenterology outpatient department of the institute from January 2010 to June 2014. All patients were apparently healthy without any clinical features of obvious liver disease. Once the patient was found to be HCV positive, a series of investigations including liver function test, ultrasound abdomen, HCV RNA quantification, and genotype determination had been performed for further management. A liver biopsy was done taking into account various parameters mentioned above for the assessment of disease activity and fibrosis.

In the patients where records revealed any past history of chronic liver disease or decompensation of liver function, alcohol consumption more than 20 g/day, hepatotoxic drug, any systemic illnesses such as diabetes mellitus, and those having co-infection with HIV or hepatitis B virus were excluded from the study.

Biochemical and serological tests

Routine hemogram, lipid profile, serum insulin, fasting blood sugar, and liver function test were done in all the patients. The cutoff for the upper limit of normal (ULN) for ALT was >40 U/l. HCV positivity was assessed using a commercial ELISA kit Monolisa HCV Ag-Ab ultra V2 (Bio-Rad, France). Serum HCV RNA titers were quantified using a reverse transcription-polymerase chain reaction-based kit COBAS AmpliPrep (TNAI)/TaqmanKit (Roche Diagnostics, Indianapolis, USA). The genotyping was done using commercial kit Siemens Versant HCV Genotype 2.0 Assay (LiPA) (Siemens Healthcare GmbH, Erlangen, Germany). The lower limit of detection was 250 copies of HCV RNA/ml. A level of >105 copies/mL was considered as active/replicative infection.

Liver biopsy

Percutaneous liver biopsies from all the patients had been obtained under local anesthesia using 16G Tru-Cut needles. Adequacy of the liver biopsy was defined as a length of at least 1 cm, with a minimum of six portal triads. For each case, hematoxylin and eosin, Masson's trichrome, and orcein-stained slides were retrieved and reviewed by three pathologists (PS, RKG, and KM) independently. HAI and fibrosis stage were assessed using the Ishak's scoring system. The cases with a concordance of results for the activity score and fibrosis stage were included in the study. Extent of hepatitis was graded as mild (HAI ≤ 3), moderate (HAI ≤4–6), and severe (HAI ≥ 7). Fibrosis stage 0–2 was scored as low and bridging fibrosis, i.e., F > 2 as high and significant.

Statistical analyses

Results were expressed as mean ± standard deviation or percentage where indicated. Statistical analyses were performed using Chi-square and Fisher's exact tests for categorical variables. Differences were considered significant at P < 0.05.


   Results Top


The mean age of the patients was 32.2 years with a male-to-female ratio of 3:1. The mean serum ALT was 128.9 U/l (95% confidence interval). ALT was higher than the cutoff for the ULN in 76.9% of subjects.

The levels of HCV RNA varied considerably among patients ranging from 273 copies/ml to 1.7 × 1010 copies/ml. HCV RNA copy number >105 was considered as significantly increased RNA levels. Higher levels of HCV RNA were seen in 42 (37.2%) patients. Information on HCV genotype was known in 77 patients, of which 25 (32.5%) were genotype 1, 1 (1.3%) genotype 2, 43 (55.8%) genotype 3, 6 (7.8%) genotype 4, and 2 (2.6%) were genotype 5. In accordance with the other studies from India, genotype 3 was the most common cause, despite some technical selection biases in this study [Table 1].
Table 1: Patient profile and serological parameters

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The magnitude of histological activity as assessed by Ishak's scoring system was >3 in 84% of the patients, whereas 27 of the 113 (24%) asymptomatic patients had increased fibrosis stage on liver biopsy (F >2). Liver biopsies showed steatosis, lymphoid aggregate, duct injury, and lobular inflammation in 68 (60.1%), 45 (39.8%), 29 (25.6%), and 11 (9.7%) biopsies, respectively [Figure 1] and [Table 2].
Figure 1: Representative photomicrographs of the liver biopsy showing (a) expansion of a portal tract with moderate chronic inflammation, thin fibrous septae, and interface activity (H and E, ×200), (b) hepatocytes showing mixed macro and microvesicular steatosis (H and E, ×200), (c and d) Masson's trichrome, and orcein stains highlighting the portal fibrosis, respectively (H and E, ×100)

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Table 2: Summary of the liver histological parameters

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Of the 27 patients with F >2, 23 patients had increased HAI (>3), 22 had increased serum ALT (>40 U/L), and only 14 (52%) had increased RNA titers (>105 IU/ml). Of the remaining 86 patients with low stage fibrosis (F <2), 73 (85%) had increased HAI, 65 (75%) had increased serum ALT, and 57 (66%) had increased RNA levels.

A higher HAI score (HAI >3) showed a significant correlation with high ALT levels (>40 U/l) (P = 0.01). However, stage of fibrosis did not correlate with ALT levels (P = 0.52). HAI or stage of fibrosis on liver biopsy did not reveal any significant correlation with serum HCV RNA titers (P = 0.36 and 0.17, respectively). Nearly 68/113 (60.1%) of biopsies showed steatosis, of which 20 involved more than 30% of the hepatic parenchyma. HCV RNA titers or serum ALT did not correlate with the degree of steatosis (P = 0.42 and 0.14, respectively) further highlighting the role of liver biopsy.

Concomitant high ALT and HCV RNA levels were found in 61 (53.9%) patients. Sixty-two of the 96 (64.5%) patients with HAI >3 showed higher serum HCV RNA levels, whereas 56 (49.5%) patients had both higher ALT and HCV RNA levels. However, the relation was statistically not significant (P = 0.36). The two most common type of the HCV genotype 1 and 3 did not show any significant differences among various parameters included in the study.


   Discussion Top


Advanced fibrosis/cirrhosis is an important factor for determining the type and duration of treatment. In patients with advanced fibrosis or cirrhosis, viral eradication effectively decreases the rate of decompensation and reduces but does not abolish the risk of development of HCC. Thus, they still need a close surveillance.

Among HCV-infected patients, about 25%–30% become symptomatic, but majority of them are undiagnosed or incidentally detected.[3] In India, this proportion may be even worse due to lack of awareness, inadequate government initiatives, and health-care infrastructure in rural areas. Chronicity is the hallmark of HCV infection, and about 80% of the patients may eventually develop chronic disease.[4] Chronic HCV infection is defined as persistence of the virus for more than 6 months after the initial infection. Often chronic HCV infection is asymptomatic for many years, and individuals harboring the virus may remain unrecognized unless tested or discovered incidentally such as during blood donation, routine health checkup, or an investigation of deranged liver function test. Over a period of time, chronic HCV infection ultimately may lead to progressive liver fibrosis with resultant cirrhosis, end-stage liver disease (decompensation), and HCC. Smith et al.[5] and Di Bisceglie et al.[6] independently reported chronic HCV infection as the leading cause of HCC and the most common indication for liver transplantation in the USA. Newer government initiatives, guidelines, and improvement of health-care infrastructure across the countries will further increase the number of newly diagnosed cases as well as cases with above-mentioned complications.

Puri et al.[1] have recently published revised guidelines for the treatment of HCV patients in Indian subcontinent under Indian National Association for Study of the Liver forum. In India, sofosbuvir was first introduced in March 2015. In our institute, liver biopsy protocols significantly changed and revised after the availability of sofosbuvir. Earlier, it was done in all the cases of genotype 1 and patients with persistently normal ALT levels in genotype 2 and 3 HCV infections. Currently, liver biopsy is done predominantly in unexplained elevation of aspartate transaminase (AST)/ALT in the absence of detectable viral levels or persistently normal AST/ALT with very high viral load and genotype has no role in the decision for biopsy. In our study, all the cases were diagnosed during pre-sofosbuvir era which may have led to a relatively higher prevalence (25.6%) of HCV genotype 1 in comparison to the previously published studies (17%)[7] and 13.1%[8] from the central and north India.

Earlier, Ghany et al. proposed a treatment algorithm for chronic HCV infection based on genotype. Liver biopsy was recommended in all patients infected with genotype 1, whereas optional in genotype 2 and 3 as >80% of such cases showed SVR after standard care of treatment.[9] However, recently, it is revealed that genotype 3, the most common subtype in India, is frequently associated with steatosis which is a predictor of relapse.[10] In addition, decreased effectiveness of sofosbuvir in genotype 3 is also reported.[11] In our study, genotype 3 comprised 55.8% (43/77) of the patients, of these 65.12% (28/43) biopsies showed steatosis of any degree and 18% of the total study population showed significant steatosis (>30%). Furthermore, HCV RNA titers or serum ALT did not correlate with the degree of steatosis (P = 0.42 and 0.14, respectively). Liver biopsy may thus be an important tool in IDHCV patients, for assessment of “significant” steatosis, which may impact treatment, follow-up protocols, and outcome.

The evaluation of viral load and LFT, particularly if performed at a single occasion, is not always sufficient to predict the disease activity and fibrosis stage. In this study, only 49.5% of the biopsies with high HAI activity (Ishak's score >3) showed a corresponding higher ALT and HCV RNA levels. Although a number of cases in our study were less, it also revealed 5 patients with both low viral load and normal ALT levels having significant activity and fibrosis. Earlier, Zeuzem et al.[12] in their study including 486 patients of HCV infection with at least three normal ALT levels during an 18-month period reported that 30% of patients had significant fibrosis on liver biopsy. We found a significant correlation of ALT with the disease activity (HAI) (P = 0.01) but not with the fibrosis stage (P = 0.52). Similarly, serum viral RNA load did not reveal any significant correlation, neither with activity (P = 0.36) nor with the fibrosis (P = 0.17).

Fibrosis is the most relevant factor to evaluate severity of disease, patient selection for treatment, assessment of response to therapy, and prognosis. In IDHCV, the patient is asymptomatic, and HCV RNA and ALT levels do not correlate with the stage of fibrosis, the mainstay for treatment. Hence, accurate staging of the fibrosis is very important. In this study, 24% of the biopsies had a significant higher fibrosis stage. Ultrasonography is reliable for detecting compensated cirrhosis with portal hypertension but not in the absence of portal hypertension. With the advancement in the imaging techniques, a number of newer noninvasive measures such as fibroscan, shear-wave elastography, and acoustic radiation force impulse (ARFI) are available for evaluation of the extent of fibrosis which allow the detection of cirrhosis without portal hypertension. Most of these techniques are based on liver stiffness and viscosity which are poor predictors of disease activity and steatosis.[13] Furthermore, due to frequent association of steatosis in genotype 3, fibroscan may lead to a false-positive report.[14] However, in liver biopsy, fibrosis is assessed by architectural disorganization and measured semi-quantitatively through different scoring scales such as Metavir and Ishak. Morphometric analysis of collagen proportion area (CPA) and qfibrosis can be done in the biopsy samples. The sensitivity and specificity of noninvasive assessment of fibrosis remains up to a maximum of 86%.[15] Fibrosis and necroinflammatory activity are the main determinants of transient elastography in chronic viral hepatitis. As elastographic fibrosis staging is influenced by disease activity and steatosis; hence, a diagnostic liver biopsy is necessary for a reliable monitoring of the course of viral hepatitis or to increase the reliability of monitoring using these noninvasive techniques.[16] Similarly, Chen et al.[17] and Vispo et al.[18] reported that degree of necroinflammatory activity can independently and significantly exaggerate liver fibrosis evaluation by ARFI. Kumar et al.[19] also found that discordant results between transient elastography and liver biopsy assessment of fibrosis in their study for chronic hepatitis B patients. In another study, Chen et al.[20] found CPA as superior and independent of severe necroinflammation to ARFI elastography for evaluation of significant fibrosis score (≥2). Fibroscan may not accurately discriminate between patients with F2 and F3 stage. Furthermore, In India, HCV genotype 3 is the most common subtype, which was also replicated in our study (55.8%). Among different HCV genotypes, genotype 3 is known to cause maximum steatotic changes. Macaluso et al.[14] showed that moderate-to-severe steatosis affects the accurate assessment of fibrosis through liver stiffness. Based on the importance of each factor which has a significant bearing on the degree of fibrosis evaluation by different methods, it is notable that noninvasive techniques and liver biopsy are both subject to certain limitations; however, using them as complementary tools may be beneficial as fibrosis is the most important factor guiding treatment.

In this study, about 18% of the patients had significant steatosis (>30%) which highlights the importance of liver biopsy for prognosis and a better management protocol. In addition to fibrosis, other activity determining histological parameters such as HAI, lymphoid aggregates, duct injury, lobular inflammation, and steatosis has reasonably important bearing on deciding treatment regimen and outcome predictability. Several studies reported non-HCV-related histological features such as steatosis and excess hepatocellular iron deposits which can affect disease progression and impede on treatment response.[10]

It is increasingly clear that these methods will not completely replace liver biopsy. Instead, noninvasive methods and liver biopsy should be used in an integrated approach for more efficient and convenient management of patients with chronic hepatitis C.[21]

HCV genotype 3 may be associated not only with severe steatosis but also with accelerated fibrosis progression rate and increased oncogenesis. Hence, the tissues of liver biopsies can serve as an important material which can be retrieved from the archives and used for future research to explore fibrosis progression and oncogenesis in HCV.[11]

The major lacunae of the study include retrospective data with a small number of patients, from pre-sofosbuvir era in India, absence of noninvasive liver stiffness measurement for comparison with fibrosis stage in biopsies, and lack of follow-up.


   Conclusion Top


About a quarter of the incidentally detected asymptomatic patients of HCV infection may show significant fibrosis and other histological changes such as steatosis on liver biopsy which bears significant implications on management and prognosis. Noninvasive techniques of liver fibrosis assessment are affected by steatosis and other histological changes and have limitations in quantification of fibrosis and disease activity evaluation. Serum ALT level, HCV RNA, and anti-HCV titers are also poor predictors of extent of liver injury, steatosis, and stage of fibrosis. Liver biopsy is gold standard which when incorporated with the other noninvasive techniques may help the clinician effectively for therapeutic and prognostic guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Puri P, Anand AC, Saraswat VA, Acharya SK, Dhiman RK, Sarin SK, et al. Indian National Association for Study of the Liver (INASL) guidance for antiviral therapy against HCV infection in 2015. J Clin Exp Hepatol 2015;5:221-38.  Back to cited text no. 1
    
2.
Lebovics E, Czobor K. Screening, diagnosis, treatment, and management of hepatitis C: A novel, comprehensive, online resource center for primary care providers and specialists. Am J Med 2014;127:e11-4.  Back to cited text no. 2
    
3.
Kamal SM. Acute hepatitis C: A systematic review. Am J Gastroenterol 2008;103:1283-97.  Back to cited text no. 3
    
4.
Huffman MM, Mounsey AL. Hepatitis C for primary care physicians. J Am Board Fam Med 2014;27:284-91.  Back to cited text no. 4
    
5.
Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo CG, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep 2012;61:1-32.  Back to cited text no. 5
    
6.
Di Bisceglie AM, Lyra AC, Schwartz M, Reddy RK, Martin P, Gores G, et al. Hepatitis C-related hepatocellular carcinoma in the United States: Influence of ethnic status. Am J Gastroenterol 2003;98:2060-3.  Back to cited text no. 6
    
7.
Hazari S, Panda SK, Gupta SD, Batra Y, Singh R, Acharya SK, et al. Treatment of hepatitis C virus infection in patients of Northern India. J Gastroenterol Hepatol 2004;19:1058-65.  Back to cited text no. 7
    
8.
Hissar SS, Goyal A, Kumar M, Pandey C, Suneetha PV, Sood A, et al. Hepatitis C virus genotype 3 predominates in north and central India and is associated with significant histopathologic liver disease. J Med Virol 2006;78:452-8.  Back to cited text no. 8
    
9.
Ghany MG, Strader DB, Thomas DL, Seeff LB, American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: An update. Hepatology 2009;49:1335-74.  Back to cited text no. 9
    
10.
Shah SR, Patel K, Marcellin P, Foster GR, Manns M, Kottilil S, et al. Steatosis is an independent predictor of relapse following rapid virologic response in patients with HCV genotype 3. Clin Gastroenterol Hepatol 2011;9:688-93.  Back to cited text no. 10
    
11.
Goossens N, Negro F. Is genotype 3 of the hepatitis C virus the new villain? Hepatology 2014;59:2403-12.  Back to cited text no. 11
    
12.
Zeuzem S, Diago M, Gane E, Reddy KR, Pockros P, Prati D, et al. Peginterferon alfa-2a (40 kilodaltons) and ribavirin in patients with chronic hepatitis C and normal aminotransferase levels. Gastroenterology 2004;127:1724-32.  Back to cited text no. 12
    
13.
Deffieux T, Gennisson JL, Bousquet L, Corouge M, Cosconea S, Amroun D, et al. Investigating liver stiffness and viscosity for fibrosis, steatosis and activity staging using shear wave elastography. J Hepatol 2015;62:317-24.  Back to cited text no. 13
    
14.
Macaluso FS, Maida M, Cammà C, Cabibbo G, Cabibi D, Alduino R, et al. Steatosis affects the performance of liver stiffness measurement for fibrosis assessment in patients with genotype 1 chronic hepatitis C. J Hepatol 2014;61:523-9.  Back to cited text no. 14
    
15.
Afdhal NH, Bacon BR, Patel K, Lawitz EJ, Gordon SC, Nelson DR, et al. Accuracy of fibroscan, compared with histology, in analysis of liver fibrosis in patients with hepatitis B or C: A United States multicenter study. Clin Gastroenterol Hepatol 2015;13:772-90.  Back to cited text no. 15
    
16.
Fraquelli M, Rigamonti C, Casazza G, Donato MF, Ronchi G, Conte D, et al. Etiology-related determinants of liver stiffness values in chronic viral hepatitis B or C. J Hepatol 2011;54:621-8.  Back to cited text no. 16
    
17.
Chen SH, Li YF, Lai HC, Kao JT, Peng CY, Chuang PH, et al. Effects of patient factors on noninvasive liver stiffness measurement using acoustic radiation force impulse elastography in patients with chronic hepatitis C. BMC Gastroenterol 2012;12:105.  Back to cited text no. 17
    
18.
Vispo E, Barreiro P, Del Valle J, Maida I, de Ledinghen V, Quereda C, et al. Overestimation of liver fibrosis staging using transient elastography in patients with chronic hepatitis C and significant liver inflammation. Antivir Ther 2009;14:187-93.  Back to cited text no. 18
    
19.
Kumar M, Rastogi A, Singh T, Bihari C, Gupta E, Sharma P, et al. Analysis of discordance between transient elastography and liver biopsy for assessing liver fibrosis in chronic hepatitis B virus infection. Hepatol Int 2013;7:134-43.  Back to cited text no. 19
    
20.
Chen SH, Peng CY, Lai HC, Chang IP, Lee CJ, Su WP, et al. Head-to-head comparison between collagen proportionate area and acoustic radiation force impulse elastography in liver fibrosis quantification in chronic hepatitis C. PLoS One 2015;10:e0140554.  Back to cited text no. 20
    
21.
Castera L, Bedossa P. How to assess liver fibrosis in chronic hepatitis C: Serum markers or transient elastography vs. Liver biopsy? Liver Int 2011;31 Suppl 1:13-7.  Back to cited text no. 21
    

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Correspondence Address:
Rakesh Kumar Gupta
Department of Pathology, Academic Block, G B Pant Institute of Post Graduate Medical Education and Research, Jawaharlal Nehru Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_240_17

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Ranjan Agrawal
Indian Journal of Pathology and Microbiology. 2018; 61(3): 309
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