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PubMed1994

Thromboxane and pulmonary morphometry in the development of the pulmonary hypertensive response to group B streptococcus.

OBJECTIVE: To clarify the mechanism of the development of a severe pulmonary hypertensive response to group B streptococcus. DESIGN: Prospective, randomized controlled trial. SUBJECTS: Twelve chronically instrumented and six age-matched uninstrumented newborn piglets. INTERVENTIONS: Six animals received eight injections of group B streptococcus over an 11-day period (control group). Six additional animals (pretreatment group) were given 3 mg/kg of dazmegrel, a thromboxane synthase blocking agent, before each dose of group B streptococcus to prevent the pulmonary hypertensive response and to control for any secondary arterial remodeling. MEASUREMENTS AND MAIN RESULTS: Hemodynamic measurements, pulmonary arterial morphometry, and thromboxane concentrations were examined in the instrumented animals. Lungs from the uninstrumented piglets were examined to determine morphometric norms for this population. The animals given only group B streptococcus developed a significant pulmonary hypertensive response after five daily doses (+6.8 +/- 2.0 [SEM] mm Hg, p < .05) which became pronounced after eight doses (+13.2 +/- 1.0 mm Hg). Pulmonary hypertension was not observed in the pretreatment group when dazmegrel was given; however, on the final day in this group, dazmegrel was withheld before group B streptococcus dosing and a significant pulmonary hypertensive response was observed (+20 +/- 1.6 mm Hg). The medial thickness of pulmonary arteries was not different between the two groups nor when compared with that of six normal, uninstrumented animals. Plasma thromboxane B2 concentrations were determined from blood samples taken before and after group B streptococcus infusion at the first, seventh and eighth (final) dosing. Thromboxane concentrations increased significantly on days 7 and 8 in the control group (578 +/- 312 to 752 +/- 372 pg/mL, 638 +/- 201 to 1462 +/- 295 pg/mL, respectively) and on day 8 in the pretreatment group (545 +/- 160 to 705 +/- 187 pg/mL). CONCLUSIONS: We conclude that the development of potentiated pulmonary hypertension is not due to pulmonary arterial remodeling, but is associated with increased thromboxane production.

Analysis of Variance↗
PubMed1989

DNA-DNA hybridization studies and phenotypic characteristics of strains within the 'Streptococcus milleri group'.

Twenty-five strains resembling 'Streptococcus milleri' were compared by DNA-DNA hybridization, by whole-cell-derived polypeptide patterns on SDS-PAGE, and by biochemical tests. Four homology groups were revealed by DNA-DNA hybridization. DNA homology groups 1, 2 and 3 were closely related and contained the type strains NCDO 2226 (Streptococcus constellatus), NCDO 2227 (Streptococcus intermedius) and NCTC 10713 (Streptococcus anginosus), respectively. DNA homology group 4 consisted of four strains received as variants of Streptococcus intermedius which were found not to be closely related to strains in groups 1-3. The data from SDS-PAGE polypeptide patterns and biochemical tests supported the recognition of three centres of variation within the 'Streptococcus milleri group' corresponding to DNA homology groups 1-3 and indicated that strains of DNA homology group 4 are members of an as yet undescribed species within the viridans streptococci.

Bacterial Proteins↗
PubMed1999

Genetic approaches to the identification of the mitis group within the genus Streptococcus.

The usefulness and reliability of partial sequence analysis of the manganese-dependent superoxide dismutase gene (sodA), autolysin (lytA) gene amplification and species-specific PCR based on the D-alanine:D-alanine ligase (ddl) gene for differentiating each member of the mitis group of the genus Streptococcus was investigated. On the phylogenetic tree based on sodA partial sequences (366 bp) from 96 strains, including all species currently within the mitis group isolated in different geographic areas (mainly Japan and the UK), eight well separated clusters were generated corresponding to recognized species, and all strains fell into those clusters to which they had also been assigned by DNA-DNA hybridization. The Streptococcus pneumoniae sub-cluster was located within the Streptococcus mitis cluster, but the sodA gene of S. pneumoniae was very conserved and therefore could be separated from all other species examined. Furthermore, the lytA gene amplification approach could also be used to differentiate S. pneumoniae from other species. The species-specific amplification product of the ddl gene was successfully detected in Streptococcus sanguinis and Streptococcus gordonii, but failed to be detected in some strains of Streptococcus oralis including the type strain and S. mitis. We conclude that the partial sequence analysis of the sodA gene could be applied globally as a reliable and easy method for the accurate identification of all species currently within the mitis group.

Alanine↗
PubMed2006

Isolation and characterization of Streptococcus mutans in heart valve and dental plaque specimens from a patient with infective endocarditis.

Streptococcus mutans, known to be an aetiologic agent of dental caries, also causes infective endocarditis (IE), although a comparison of isolates from the oral cavity and infected heart valve of the same patient has not been reported. In the present study, infected heart valve and dental plaque samples from a patient with IE were analysed. Broad-range PCR with DNA sequencing revealed that 50 clones from the dental plaque isolates were composed of oral streptococci and periodontopathic bacteria, whereas only Streptococcus mutans was detected in 50 clones from the heart valve. Eighteen strains of Streptococcus mutans were isolated from dental plaque and seven from the heart valve, and the biochemical properties of each were in accordance with those of Streptococcus mutans. DNA fingerprinting analysis revealed that all the oral isolates of Streptococcus mutans had similar patterns, which were different from those of the isolates from the infected heart valve. Western blotting using glucosyltransferase (GTF)-specific antiserum showed that the seven strains from the heart valve lacked the three types of intact GTF. In addition, the sucrose-dependent adhesion rates of these isolates were significantly lower than those of the oral isolates (P<0.001). Furthermore, the isolates from the heart valve were less susceptible to erythromycin and kanamycin. These results indicate that the properties of the Streptococcus mutans strains isolated from the infected valve were different from those of typical oral strains, which may be related to the effects of IE.

Anti-Bacterial Agents↗
PubMed2001

Cloning and DNA sequencing of the surface protein antigen I/II (PAa) of Streptococcus cricetus.

We have cloned and sequenced the gene encoding the surface protein antigen PAa (antigen I/II family) from Streptococcus cricetus E49 (serotype a) using degenerate PCR. The deduced amino acid sequence of PAa reveals two repeating regions (A region; alanine-rich region, P region; proline-rich region). Two additional tandem repeats were found in the A region and part of the P region was deleted compared to antigen I/II. Homology and phylogenetic analyses reveal that PAa is homologous to Streptococcus sobrinus PAg rather than Streptococcus mutans PAc. Using degenerate PCR a gene homologous to PAc was identified in Streptococcus intermedius, but not found in Streptococcus rattus or Streptococcus anginosus.

Animals↗
PubMed1988

Evaluation of the Rapid Mastitis Test for identification of Staphylococcus aureus and Streptococcus agalactiae isolated from bovine mammary glands.

A latex agglutination test system (Rapid Mastitis Test [RMT]; Immucell, Portland, Maine) containing reagents for the identification of Staphylococcus aureus and Streptococcus agalactiae from bovine intramammary infections was evaluated with 527 staphylococcal and 267 streptococcal isolates. The RMT Staphylococcus aureus reagent detected 94.2% of 242 Staphylococcus aureus isolates, 80% of 25 Staphylococcus intermedius isolates, and 42.8% of 21 tube coagulase-positive Staphylococcus hyicus isolates. All Streptococcus agalactiae isolates were correctly identified by the RMT Streptococcus agalactiae reagent. Cross-reactions were observed with one Streptococcus dysgalactiae and three Streptococcus uberis strains. The RMT was found to be an acceptable method for the detection of Staphylococcus aureus and Streptococcus agalactiae isolated from bovine mammary glands. The occurrence of coagulase-positive staphylococci other than Staphylococcus aureus requires biochemical testing for species level identification.

Animals↗
PubMed2005

Loop-mediated isothermal amplification method targeting the lytA gene for detection of Streptococcus pneumoniae.

It is difficult to separate Streptococcus pneumoniae from the genotypically similar species Streptococcus mitis and Streptococcus oralis, which are commensals of the human oral cavity. A novel nucleic acid amplification technique, loop-mediated isothermal amplification (LAMP), which amplifies DNA under isothermal conditions (63 degrees C) with high specificity, efficiency, and rapidity, was examined regarding its applicability for detecting S. pneumoniae. An S. pneumoniae-specific LAMP primer targeting the lytA gene was designed. The primer specificity was validated using 10 Streptococcus and 7 non-Streptococcus species. Within 60 min, the assay could detect 10 or more copies of purified S. pneumoniae DNA with a sensitivity 1,000 times that of conventional PCR. Clinical isolates of 21 other strains (3 S. oralis, 17 S. mitis, and 1 Streptococcus species) that harbor virulence-factor-encoding genes (lytA or ply) were tried to differentiate S. pneumoniae. The detection of S. pneumoniae in clinical isolates was more selective using the LAMP method than using conventional PCR. Therefore, LAMP appears to be a sensitive and reliable means of diagnosing S. pneumoniae infection.

Bacterial Typing Techniques↗
PubMed2001

Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review.

The pulmonic valve is the least commonly involved valve in infective endocarditis. Pulmonic valve endocarditis is usually associated with tricuspid valve endocarditis, and isolated pulmonic valve endocarditis is exceedingly rare. The predisposing factors for developing pulmonic valve endocarditis include a congenitally anomalous pulmonic valve, intravenous drug abuse, and the presence of indwelling intravenous or flow-directed pulmonary artery catheters. More cases of group B streptococcus endocarditis are being reported. The risk factors for group B streptococcus endocarditis include diabetes mellitus, cancer, alcoholism, malnutrition, immunocompromised status, intravenous drug abuse, postpartum and postabortion states, and underlying valvular disease. The vegetations of this type of endocarditis are usually large and have a higher tendency to result in embolism. The presentation of group B streptococcus endocarditis is usually acute and may result in rapid valve destruction if not treated promptly. A case of isolated pulmonic valve endocarditis caused by group B streptococcus, Streptococcus agalactiae, is presented that was diagnosed with multiplane transesophageal echocardiography in a 40-year old, alcoholic, malnourished man, who was successfully treated with intravenous penicillin G. The literature on the isolated pulmonic valve endocarditis caused by group B streptococcus is reviewed.

Adult↗
PubMed1998

Effect of haptoglobin phenotypes on growth of Streptococcus pyogenes.

The haptoglobin (Hp) 2-1 and 2-2 phenotypes have been shown to agglutinate Streptococcus pyogenes carrying the membrane antigen T4. In this study, the growth rate of two strains of Streptococcus pyogenes (T1 and T4) in human serum was compared among haptoglobin phenotypes in vitro. During incubation for 16 hours in serum of different haptoglobin types, only Hp 2-1 and Hp 2-2 sera showed an inhibitory effect on growth, Hp 2-2 being 1.85 times more potent than Hp 2-1. Growth of Streptococcus pyogenes T4 negatively correlated with the serum concentration of Hp 2-1 (r = -0.908) and Hp 2-2 (r = -0.953). Haptoglobin-depleted serum had no inhibitory effect on bacterial growth. Addition of haemoglobin and ferric citrate to the serum accelerated the growth of Streptococcus pyogenes T4 (P <0.05) but not in Hp 2-2 serum. Haptoglobin types 2-1 and 2-2 can be regarded as inhibitors of Streptococcus pyogenes growth in vitro. These data point towards a potential protective role of Hp 2-2 in Streptococcus pyogenes infection in vivo, independently of iron uptake.

Antigens, Bacterial↗
PubMed2004

Significance, management and prevention of Streptococcus agalactiae infection during the perinatal period.

The highest annual death rate during the first five decades of life occurs in the first year, particularly during the perinatal period between the onset of labor and 72 h after birth. Invasive bacterial disease evoking the severe inflammatory response syndrome is a leading cause of perinatal morbidity and mortality. Group B streptococcus (Streptococcus agalactiae) is the most important pathogen in this period of life, although the concept of intrapartum antimicrobial prophylaxis has impressively reduced the rate of culture-proven invasive infection in neonates. This strategy, however, has considerable limitations since group B streptococcus-related stillbirths or prematurity and late-onset sepsis cannot be prevented. Moreover, the use of intrapartum antimicrobial prophylaxis has significantly increased the use of antibiotics during labor and therefore may select for intrapartum infections caused by other bacteria, including those resistant to antibiotics. Several advances in the development of vaccines and research on virulence factors and pathways involved in the immune response to group B streptococcus have been accomplished within the last years, including complete sequencing of the group B streptococcus genome. Development of effective vaccines and implementation of vaccination strategies will be one of the key challenges in the future for prevention of neonatal group B Streptococcus infections.

Animals↗
PubMed2003

Infectious endocarditis from Streptococcus bovis associated with colonic carcinoma: case report and literature review.

BACKGROUND: Many studies in the literature have warned of the need for investigation of colonic lesions among patients, especially elderly ones, who have bacteremia and/or endocarditis from Streptococcus bovis. Bacteremia and infectious endocarditis from Streptococcus bovis may be related to the presence of neoplastic lesions in the large intestine and hepatic disease. AIM: This report describes a patient who presented infectious endocarditis from Streptococcus bovis associated with colonic carcinoma and tubular-villous adenomas. CONCLUSIONS: The finding of this bacterium among patients with septicemia and/or endocarditis is also related to the presence of villous or tubular-villous adenomas in the large intestine. For this reason, complete and detailed investigation of the large intestine must be performed in patients with infectious endocarditis, even in the absence of intestinal symptoms. An increased incidence of this condition or hepatic dysfunction has been reported among patients with infectious endocarditis from Streptococcus bovis. Patients with infectious endocarditis from Streptococcus bovis and normal colonoscopy may be included in the group at risk for developing colonic cancer. The knowledge that there is an association between endocarditis from Streptococcus bovis and carcinoma of the colon has important clinical implications. If the lesion can be discovered at an early stage, curative resection may become possible.

Adenocarcinoma↗
PubMedDate not supplied

[The isolation of Streptococcus morbillorum from vaginal exudates].

We have tested 195 vaginal secretions sent by Gynecology Service of this hospital between the years 1988-1990. We achieved positive culture for streptococci in 58 (30%) of these cultures, 26 (44.8%) corresponding to Streptococcus morbillorum 9 (15.5%), to Gardnerella vaginalis 5 (8.6%), to Enterococcus faecalis-durans and to Streptococcus agalactiae, 3 (5.1%) to Streptococcus mitis and milleri 2 (3.4%), to Streptococcus bovis and cremoris, and 1 (1.7%) to Streptococcus salivarius, equinus and sanguis II respectively. We previously found that 52.8% of these patients were positive for vaginal candidiasis. The bacteriological identification done by the API 20 STREP System (bioMerieux GmbH, Nútingen, Germany) provides a typical pattern ("good identification") for the Streptococcus morbillorum.

Adolescent↗
PubMed2004

[Value of a rapid test for identification of beta-hemolytic streptococcus antigens in children with streptococcal pharyngitis].

Beta-hemolytic group A streptococcus (Streptococcus pyogenes) is the most common bacterial agent associated with the upper respiratory tract infections in humans. The most frequently group A streptococcus-associated disease is pharyngitis. Males and females are equally affected by group A streptococcus. There is seasonal increase in the prevalence of group A streptococcus-associated pharyngitis. Streptococcal pharyngitis is most prevalent in winter and early spring with higher incidence of disease observed in crowded population such as school children. Early diagnosis and treatment of group A streptococcal pharyngitis has been shown to reduce the severity of symptoms and further complications such as rheumatic fever and glomerulonephritis. The conventional methods used for identification of group A streptococci depend on isolation and identification of the organism on blood agar plates. These methods usually require 18-24 hours of incubation at 37 degrees C. Such delay in identifying the group A streptococcus has often made physicians to administer therapy without first disclosing the etiological agent. Development of immunologic tests, capable of detecting the group A streptococcal antigen directly from the throat swabs, produced rapid test results employed for better treatment of patients. STREP A test is a rapid immunochromatographic test for the detection of group A streptococci from throat swabs or culture. The accuracy of the test does not depend on the organism viability. Instead, group A strep antigen is extracted directly from the swab and identified using antibodies specific for the group A carbohydrates. We compared rapid test with conventional throat swab in 40 children, who met Centor criteria for streptococcal pharyngitis (absence of cough, high fever, purulent pharyngitis, enlarged and painful cervica lymph nodes). Overall congruence of rapid test and culture was 94%. Test is easy to perform and it is recommended as the first diagnostic test for management of children with streptococcal pharyngitis. In children with negative test, but with characteristics highly suggestive of streptococcal infection, throat culture should be performed.

Adolescent↗
PubMedDate not supplied

[Resistance to penicillin and other antimicrobials in 103 clinical isolations of Streptococcus pneumoniae (2000-2001)].

BACKGROUND: To determine in our hospital the sensitivity of isolations of Streptococcus pneumoniae to penicillin, as well as to analyse the association of resistance to penicillin and other antimicrobials and the activity of cefotaxime and cefepime in pencillin resistant strains of Streptococcus pneumoniae. METHODS: The sensitivity was determined on 103 isolations of Streptococcus pneumoniae, from clinical samples from the years 2000-2001, to penicillin, eritromycine, cloramfenicol, tetracycline, cotrimoxazol, cefotaxime, cefepime and levofloxacine. RESULTS: Sixty-eight percent of the isolations were sensitive to penicillin, while some 32% of the isolated strains of Streptococcus pneumoniae were penicillin resistant, with 7.7% showing a high degree of resistance. Resistance to eritromycine, cloramfenicol, tetracycline, cotrimoxazol and levofloxacine was 38.8%; 9.7%; 20.4%; 25.2% and 2.9% respectively, increasing to values of 66.6%; 30.3%; 48.5%; 72.7% and 9.1% in the 33 penicillin resistant strains. Resistance to cefotaxime and cefepime was 9.7% and 10.6% respectively. CONCLUSIONS. A high percentage of strains of Streptococcus pneumoniae show some degree of resistance to penicillin, but with lower figures than in other studies carried out at a national level. Similarly, it was demonstrated that resistance to penicillin is significantly associated (p < 0.001) with resistance to all the antimicrobials studied, except for levofloxacine. The resistances to cefotaxime and cefepime were comparable, with less activity being observed in these when facing penicillin resistant strains of Streptococcus pneumoniae.

Adult↗
PubMed2001

[Clinical and bacteriological significance of the Streptococcus milleri group in deep neck abscesses].

Streptococcus constellatus, S. intermedius, and S. anginosus, the three species of the S. milleri group, form part of the normal flora most commonly found in the mouth, throat, gastrointenstinal tract, and genital tract. The S. milleri group has become known as an important pathogen in abscess disease, but little attention has been paid to their role in deep neck abscesses. We have treated 9 patients with deep neck abscesses relating to the S. milleri group since 1991, and regarded this group as an important pathogen also in these abscesses. We studied the frequency of the S. milleri group isolated from deep neck abscesses in our cases and from the literature and discuss clinical significance and bacteriological pathogenesis. Cases numbered 27 treated at our facility since 1991 and 200 cases reported in the Japanese literature since 1990. Of our 9 cases, 4 originated from acute pharyngitis, 3 from peritonsillar abscesses, and 2 from odontogenic infection. Serious complications such as mediastinitis, cervical necrotizing fasciitis, sepsis accompanied by disseminated intravascular coagulation, and spondylitis of the cervical vertebrae were seen in 4 cases. Among organisms isolated, the S. milleri group appeared to be a pathogen contributing to abscess formation and to serious complications. The genus Streptococcus was most frequently isolated both in our 27 cases (66.7%) and the 200 in the literature (45.5%). Among species of the genus Streptococcus, the S. milleri group numbered the highest in our cases at 33.3% but only 8.5% in the literature. Cases in the literature, however, contained many unknown species of Streptococci--31.5% vs. 18.5% in our cases. alpha-streptococcus was frequently reported in the literature among unknown species of Streptococci--36 of 63. Culture-negative cases were also numbered more in the literature than in our case--29.0% vs. 18.5%. Special conditions and procedures are required to suitably isolate and detect the S. milleri group. Since not all facilities use identical techniques in routine bacteriological examination, a considerable number of the S. milleri group could be missed in unknown species of Streptococci or alpha-streptococcus and culture-negative cases. The detailed pathogenesis of the S. milleri group remains to be clarified. Infection by normal flora on mucosa is thought to occur due to an imbalance between organisms and host defense in deep neck abscesses. Some strains of the S. milleri group have been reported to produce many tissue-destroying enzymes such as collagenase and hyaluronidase. The co-existence of the S. milleri group with some anaerobe strains has also been suggested to accelerate inflammation. We discuss the mechanism inducing the massive release of cytokines through T cell response to certain exotoxins produced by S. milleri group, as reported in toxic shock-like syndrome due to the group A beta-streptococcus and in alpha-streptococcal shock syndrome due to viridans streptococci (alpha-streptococci).

Abscess↗
PubMed2005

[Detection of virulence-associated factors of Streptococcus suis by multiplex PCR assay].

OBJECTIVE: To rapidly and sensitively detect the four virulence-associated factors of Streptococcus suis, a multiplex PCR was developed. METHODS: In the process of this reaction, four distinct DNA targets were amplified. One target was based on the serotype 2 (and 1/2) specific cps gene and the others were based on Streptococcus suis mrp, epf (epf*) and sly gene, encoding the MRP, EF(EF*) and Sly proteins of Streptococcus suis. 72 isolates, which including 48 strains of Streptococcus suis and 24 strains of negative control, and 49 clinical specimens were detected by the multiplex PCR assay. RESULTS: All PCR products were detected by electrophoresis on 1.2% agarose gels. With the 48 Streptococcus suis strains, the positive detection rates of cps2+, mrp+, epf+, epf*+ and sly+ were 16/48, 14/48, 12/48, 3/48 and 26/48,respectively. The results were confirmed by bacteriological examination. There were no specific amplification products including 49 clinical specimens and 24 negative control strains. CONCLUSION: The results demonstrated that multiplex PCR was a highly specific and sensitive diagnostic tool for the detection of virulence-associated factors of streptococcus suis.

Bacterial Proteins↗
PubMed2006

[Experimental study of the inhibitory effects of Chelidonium majus L. extractive on Streptococcus mutans in vitro].

PURPOSE: To study the inhibitory effects of Chelidonium majus L. extractive on the growth of Streptococcus mutans in vitro, and to explore its mechanism in caries prevention. METHODS: Streptococcus mutans 25175 was chosen as the experimental bacterium. The Chelidonium majus L. extractives chelidonine and chelerythrine were double diluted to different concentrations by two-fold dilution. The inhibitory effect of Streptococcus mutans was measured by slip diffusion method. The minimal inhibitory concentration(MIC) was also determined. 0.16% liquor hibitane was used as positive control. Spearman correlation was used for statistical analysis. RESULTS: Inhibition zone of Streptococcus mutans appeared in some concentration of chelerythrine, but no inhibition zone in each concentration of chelidonine. The MIC of chelerythrine was 0.78 mg/ml which determined by liquid culture medium. The concentration of chelerythrine was highly related to the inhibitory zone of Streptococcus mutans (r=0.99, P<0.01). CONCLUSION: The antibacterial activity of Chelidonium majus L. extractive chelerythrine on Streptococcus mutans was significant,and the antibacterial activity of the concentration 100 mg/ml was higher than that of 0.16% liquor hibitane (19.4 mm), indicating that chelerythrine can be used as an agent for prevention of dental caries.

Anti-Bacterial Agents↗
PubMedDate not supplied

[The importance of Streptococcus bovis systemic infections].

Streptococcus bovis is relatively common cause of bacteremia and endocarditis, especially in older persons, or in patients that have some kind of chronic disease. These infections are frequently connected with malignant, potentially malignant, or benign colorectal neoplasia. Hematogenous dissemination of Streptococcus bovis could result with various clinical manifestations, namely purulent meningitis, brain abscess, osteomyelitis, spondylodiscitis, and many different kinds of infections in AIDS patients are reported. In this report, two patients hospitalized at the Departement of Infectious Diseases at the General Hospital "Dr. Josip Bencević" in Slavonski Brod are presented. The first patient was addmited to the hospital because of fever of unknown origin, and in his blood cultures, Streptococcus bovis was isolated. He was an older man, who had undergone prostatectomy due prostatic adenoma several years before. The other patient, previously completely healthy younger man, suffered purulent meningitis caused by the same microorganism. Colon endoscopy was performed in both patients and it revealed colon polyps. Histologically, in both cases, those were benign neoplasia. In Croatia, until this report, there have been no other reports about patients suffering systemic Streptococcus bovis infections. At the same time, this report describes Streptococcus bovis purulent meningitis in a previously healthy adult, which is also extremely rare in the medical literature. Since Streptococcus bovis infections are associated with colon carcinoma, it is imperative to perform colonoscopy in each patient suffering infection with this germ, and to consider him as a high risk patient for developing colon cancer.

Adult↗