{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T03:10:16Z","timestamp":1788923416399,"version":"build-2803163510"},"update-to":[{"DOI":"10.1371\/journal.pntd.0013527","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,9,22]],"date-time":"2025-09-22T00:00:00Z","timestamp":1758499200000}}],"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T00:00:00Z","timestamp":1758067200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003141","name":"Consejo Nacional de Ciencia y Tecnologia","doi-asserted-by":"crossref","award":["FOSISS 2015-1 261482"],"award-info":[{"award-number":["FOSISS 2015-1 261482"]}],"id":[{"id":"10.13039\/501100003141","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Progressive disseminated histoplasmosis (PDH) is a leading cause of morbidity and mortality among persons with HIV (PWH) in the Americas. Clinical presentation often overlaps with other opportunistic infections \u2014especially tuberculosis (TB)\u2014 and sensitive diagnostics are frequently unavailable. In Mexico, epidemiological data on histoplasmosis in PWH are scarce. This study aims to describe the clinical and demographic characteristics along with final diagnosis of hospitalized PWH who had clinical suspicion of progressive disseminated histoplasmosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methodology\/Principal Findings<\/jats:title>\n                    <jats:p>\n                      We conducted a multicenter, prospective, cross-sectional study involving 415 hospitalized PWH and clinical suspicion of PDH across ten tertiary care hospitals in Mexico. Participants underwent comprehensive evaluation for\n                      <jats:italic>Histoplasmosis<\/jats:italic>\n                      infection, including cultures, histopathology, and urine antigen testing. Of the total cohort, 108 patients (26%) had proven PDH, 162 (39%) received an alternative diagnosis, and 145 (35%) had no definitive diagnosis. In univariate analyses, proven PDH was more frequently associated with skin lesions, thrombocytopenia, elevated AST and LDH levels (&gt;2x ULN), and micronodular infiltrates on chest imaging. In contrast, lymphadenopathy, tree-in-bud patterns, pleural effusion, hepatomegaly, and splenomegaly in imaging were more commonly observed in patients without proven PDH.\n                    <\/jats:p>\n                    <jats:p>Among patients without proven PDH, 41 met the criteria for probable PDH. Compared with proven PDH, probable cases exhibited higher rates of lymphadenopathy (73% vs 50%). Conversely, elevated AST (61% vs 39%) and LDH (74% vs 35%) levels were more frequent in proven PDH cases. While radiographic lung involvement was common in both groups, mediastinal lymphadenopathy (29% vs 12%), pleural effusion (17% vs 3.7%), and hepatomegaly (56% vs 37%) were significantly more frequent in probable PDH cases. Clinical response to antifungal therapy was higher in proven PDH (38% vs 24%), although this difference was not statistically significant.<\/jats:p>\n                    <jats:p>\n                      Compared to patients with tuberculosis (TB) alone, those with proven PDH alone showed more profound immunosuppression, with a greater proportion presenting CD4\u2009+\u2009counts &lt;50 cells\/mm\n                      <jats:sup>3<\/jats:sup>\n                      . Skin lesions, LDH elevation, and micronodular pulmonary infiltrates were also more frequent in the proven PDH group, underscoring their diagnostic relevance. In contrast, lymphadenopathy, tree-in-bud opacities, hepatomegaly, and splenomegaly were more common in TB. Importantly, TB coinfection was present in 13 patients with proven PDH (12%) and in 12 with probable PDH (29%).\n                    <\/jats:p>\n                    <jats:p>In an exploratory analysis of predictors for proven PDH, elevated LDH level was the strongest predictor (adjusted prevalence odds ratio [aPOR] of 6.82, 95% CI\u00a03.56 \u2013 13.4, p\u2009&lt;\u20090.001), followed by the presence of micronodular infiltrates on chest imaging (aPOR 1.94, 95% CI 1.06 \u2013 3.62, p\u2009=\u20090.33). In contrast, pleural effusion on imaging was the strongest negative predictor for proven PDH (aPOR 0.28, 95% CI 0.07 \u2013 0.92, p\u2009=\u20090.0498).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions\/Significance<\/jats:title>\n                    <jats:p>Histoplasmosis represents a substantial diagnostic burden among PWH in Mexico, particularly in those with advanced disease. Our findings highlight the urgent need to expand access to rapid and sensitive diagnostic tools, improve clinical awareness, and promote routine screening for PDH in PWH presenting with febrile illness, especially in TB-endemic regions. Elevated LDH levels, skin lesions, and micronodular infiltrates on chest imaging were the most useful features to differentiate proven histoplasmosis from tuberculosis and probable histoplasmosis.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pntd.0013527","type":"journal-article","created":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T17:43:06Z","timestamp":1758130986000},"page":"e0013527","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":4,"title":["Differentiating proven progressive disseminated histoplasmosis from other diagnoses in hospitalized persons with HIV and suspected progressive disseminated histoplasmosis: Findings from a clinical and demographic study in Mexico"],"prefix":"10.1371","volume":"19","author":[{"given":"Maria Dolores","family":"Niembro-Ortega","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Areli","family":"Martinez-Gamboa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Olivas-Martinez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brenda","family":"Crabtree-Ramirez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janeth","family":"Santiago-Cruz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Rangel-Cordero","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro","family":"Torres-Gonzalez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Armando","family":"Gamboa-Dominguez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victor Hugo","family":"Lozano-Fernandez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victor Hugo","family":"Ahumada-Topete","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro","family":"Martinez-Ayala","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marisol","family":"Manriquez-Reyes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan Pablo","family":"Ramirez-Hinojosa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia","family":"Rodriguez-Zulueta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jesus","family":"Ruiz-Qui\u00f1ones","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Hernandez-Leon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Norma Erendira","family":"Rivera-Martinez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Chaparro-Sanchez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaime","family":"Andrade-Villanueva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luz Alicia","family":"Gonzalez-Hernandez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sofia","family":"Cruz-Martinez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oscar","family":"Flores-Barrientos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jesus Enrique","family":"Gaytan-Martinez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Axel Cervantes","family":"Sanchez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy Guadalupe","family":"Velazquez-Zavala","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"del Rocio Reyes-Montes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esperanza Duarte","family":"Escalante","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Guadalupe Frias","family":"De Leon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose Antonio","family":"Ramirez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Lucia","family":"Taylor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose","family":"Sifuentes-Osornio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2640-2916","authenticated-orcid":true,"given":"Alfredo","family":"Ponce de Leon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,9,17]]},"reference":[{"issue":"1","key":"pntd.0013527.ref001","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1128\/CMR.00027-06","article-title":"Histoplasmosis: a clinical and laboratory update","volume":"20","author":"CA Kauffman","year":"2007","journal-title":"Clin Microbiol Rev"},{"issue":"5","key":"pntd.0013527.ref002","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1007\/s11046-020-00431-2","article-title":"Re-drawing the maps for endemic mycoses","volume":"185","author":"N Ashraf","year":"2020","journal-title":"Mycopathologia"},{"issue":"7","key":"pntd.0013527.ref003","article-title":"Considerations about the geographic distribution of histoplasma species","volume":"88","author":"TM Lucia","year":"2022","journal-title":"Appl Environ Microbiol"},{"issue":"5","key":"pntd.0013527.ref004","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1055\/s-0035-1562899","article-title":"Histoplasmosis: up-to-date evidence-based approach to diagnosis and management","volume":"36","author":"CA Hage","year":"2015","journal-title":"Semin Respir Crit Care Med"},{"issue":"11","key":"pntd.0013527.ref005","doi-asserted-by":"crossref","first-page":"2261","DOI":"10.3201\/eid2811.220542","article-title":"Prevalence of histoplasmosis among persons with advanced HIV disease, Nigeria","volume":"28","author":"RO Oladele","year":"2022","journal-title":"Emerg Infect Dis"},{"key":"pntd.0013527.ref006","volume-title":"Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV: Cryptococcosis","author":"HIV.gov","year":"2021"},{"key":"pntd.0013527.ref007","volume-title":"Guidelines for diagnosing and managing disseminated histoplasmosis among people living with HIV","author":"PAH Organization","year":"2020"},{"issue":"2","key":"pntd.0013527.ref008","doi-asserted-by":"crossref","first-page":"216","DOI":"10.4269\/ajtmh.13-0084","article-title":"Tuberculosis and histoplasmosis among human immunodeficiency virus-infected patients: a comparative study","volume":"90","author":"A Adenis","year":"2014","journal-title":"Am J Trop Med Hyg"},{"issue":"10","key":"pntd.0013527.ref009","doi-asserted-by":"crossref","first-page":"1150","DOI":"10.1016\/S1473-3099(18)30354-2","article-title":"Burden of HIV-associated histoplasmosis compared with tuberculosis in Latin America: a modelling study","volume":"18","author":"AA Adenis","year":"2018","journal-title":"Lancet Infect Dis"},{"issue":"8","key":"pntd.0013527.ref010","doi-asserted-by":"crossref","first-page":"1523","DOI":"10.3201\/eid3008.231710","article-title":"Systematic review of prevalence of histoplasma antigenuria in persons with HIV in Latin America and Africa","volume":"30","author":"P Sekar","year":"2024","journal-title":"Emerg Infect Dis"},{"key":"pntd.0013527.ref011","unstructured":"Timothy R, Ramirez BC, Shepherd BE, Mcgowan C, Sterling TR. Culture-negative TB is associated with increased mortality in HIV-infected persons. 2007;833:69923."},{"issue":"3","key":"pntd.0013527.ref012","doi-asserted-by":"crossref","first-page":"306","DOI":"10.5588\/ijtld.18.0111","article-title":"HIV-related tuberculosis: mortality risk in persons without vs. with culture-confirmed disease","volume":"23","author":"B Crabtree-Ram\u00edrez","year":"2019","journal-title":"Int J Tuberc Lung Dis"},{"issue":"3","key":"pntd.0013527.ref013","first-page":"208","article-title":"Histoplasmosis en Mexico, aspectos hist\u00f3ricos y epidemiol\u00f3gicos","volume":"11","author":"MA Vaca Mar\u00edn","year":"1998","journal-title":"Rev Inst Nal Enf Resp Mex"},{"issue":"1","key":"pntd.0013527.ref014","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1007\/s12281-011-0081-7","article-title":"Epidemiology of invasive fungal infections in Latin America","volume":"6","author":"J Sifuentes-Osornio","year":"2012","journal-title":"Curr Fungal Infect Rep"},{"issue":"1","key":"pntd.0013527.ref015","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1186\/s13256-024-04856-x","article-title":"Disseminated histoplasmosis from western Mexico-rethinking our geographic distribution of endemic fungal species: a case report and review of literature","volume":"18","author":"R Sleightholm","year":"2024","journal-title":"J Med Case Rep"},{"issue":"2","key":"pntd.0013527.ref016","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.26415","article-title":"Global prevalence of advanced HIV disease in healthcare settings: a rapid review","volume":"28","author":"N Ford","year":"2025","journal-title":"J Int AIDS Soc"},{"key":"pntd.0013527.ref017","unstructured":"Update GA. THE URGENCY OF NOW AIDS AT A. 2024."},{"key":"pntd.0013527.ref018","doi-asserted-by":"crossref","DOI":"10.3390\/jof9050558","article-title":"Tackling histoplasmosis infection in people living with HIV from Latin America: from diagnostic strategy to public health solutions","volume":"9","author":"DH C\u00e1ceres","year":"2023","journal-title":"J Fungi"},{"issue":"1","key":"pntd.0013527.ref019","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofz534","article-title":"The diagnostic laboratory hub: a new health care system reveals the incidence and mortality of tuberculosis, histoplasmosis, and cryptococcosis of PWH in Guatemala","volume":"7","author":"B Samayoa","year":"2019","journal-title":"Open Forum Infect Dis"},{"issue":"11","key":"pntd.0013527.ref020","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0006872","article-title":"Diagnostic accuracy cohort study and clinical value of the Histoplasma urine antigen (ALPHA Histoplasma EIA) for disseminated histoplasmosis among HIV infected patients: a multicenter study","volume":"12","author":"P Torres-Gonz\u00e1lez","year":"2018","journal-title":"PLoS Negl Trop Dis"},{"issue":"3","key":"pntd.0013527.ref021","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0009215","article-title":"Diagnostic accuracy of antigen detection in urine and molecular assays testing in different clinical samples for the diagnosis of progressive disseminated histoplasmosis in patients living with HIV\/AIDS: a prospective multicenter study in Mexico","volume":"15","author":"A Mart\u00ednez-Gamboa","year":"2021","journal-title":"PLoS Negl Trop Dis"},{"issue":"6","key":"pntd.0013527.ref022","doi-asserted-by":"crossref","first-page":"1367","DOI":"10.1093\/cid\/ciz1008","article-title":"Revision and update of the consensus definitions of invasive fungal disease from the european organization for research and treatment of cancer and the Mycoses Study Group Education and Research Consortium","volume":"71","author":"JP Donnelly","year":"2020","journal-title":"Clin Infect Dis"},{"issue":"4","key":"pntd.0013527.ref023","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofz073","article-title":"Histoplasmosis, an underdiagnosed disease affecting people living with HIV\/AIDS in Brazil: results of a multicenter prospective cohort study using both classical mycology tests and histoplasma urine antigen detection","volume":"6","author":"DR Falci","year":"2019","journal-title":"Open Forum Infect Dis"},{"key":"pntd.0013527.ref024","first-page":"391","article-title":"Clinical characteristics, diagnosis, treatment and outcomes of patients living with HIV and co-infected with tuberculosis and histoplasmosis: a 5-y retrospective case series","year":"2024","journal-title":"Soc TR, Med T"},{"issue":"9","key":"pntd.0013527.ref025","doi-asserted-by":"crossref","DOI":"10.1097\/QAD.0b013e3282ffde67","article-title":"AIDS-related histoplasma capsulatum var. capsulatum infection: 25 years experience of French Guiana","volume":"22","author":"F Huber","year":"2008","journal-title":"AIDS"},{"issue":"8","key":"pntd.0013527.ref026","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1086\/428842","article-title":"Disseminated histoplasmosis in patients with AIDS in Panama: a review of 104 cases","volume":"40","author":"ME Gutierrez","year":"2005","journal-title":"Clin Infect Dis"},{"key":"pntd.0013527.ref027","doi-asserted-by":"crossref","DOI":"10.3390\/jof5030073","article-title":"Histoplasmosis and tuberculosis co-occurrence in people with advanced HIV","volume":"5","author":"DH Caceres","year":"2019","journal-title":"Journal of Fungi"},{"issue":"10","key":"pntd.0013527.ref028","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1016\/S1473-3099(18)30373-6","article-title":"Histoplasmosis dethrones tuberculosis in Latin America","volume":"18","author":"AC Pasqualotto","year":"2018","journal-title":"Lancet Infect Dis"},{"issue":"11","key":"pntd.0013527.ref029","doi-asserted-by":"crossref","first-page":"2094","DOI":"10.3201\/eid2111.150278","article-title":"Histoplasmosis in HIV-infected persons, Yaound\u00e9, Cameroon","volume":"21","author":"CE Mandengue","year":"2015","journal-title":"Emerg Infect Dis"},{"key":"pntd.0013527.ref030","year":"2022"},{"key":"pntd.0013527.ref031","unstructured":"Censida e instituciones de salud garantizan tratamiento gratuito para VIH a nivel nacional. Available from: https:\/\/www.gob.mx\/salud\/prensa\/048-censida-e-instituciones-de-salud-garantizan-tratamiento-gratuito-para-vih-a-nivel-nacional"},{"issue":"3","key":"pntd.0013527.ref032","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0152444","article-title":"CD4 counts at entry to HIV care in Mexico for patients under the \u201cUniversal Antiretroviral Treatment Program for the Uninsured Population,\u201d 2007-2014","volume":"11","author":"AC Hern\u00e1ndez-Romieu","year":"2016","journal-title":"PLoS One"},{"issue":"1","key":"pntd.0013527.ref033","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1186\/s12981-021-00409-0","article-title":"Patient characteristics and determinants of CD4 at diagnosis of HIV in Mexico from 2008 to 2017: a 10-year population-based study","volume":"18","author":"A Azamar-Alonso","year":"2021","journal-title":"AIDS Res Ther"},{"key":"pntd.0013527.ref034","unstructured":"WHO. Second WHO Model List of Essential In Vitro Diagnostics. Who\/Mvp\/Emp\/201905 [Internet]. 2019;1\u201352. Available from: https:\/\/www.who.int\/publications\/i\/item\/WHO-MVP-EMP-2019.05"},{"issue":"5","key":"pntd.0013527.ref035","doi-asserted-by":"crossref","DOI":"10.1371\/journal.ppat.1008449","article-title":"Disseminated histoplasmosis: fighting a neglected killer of patients with advanced HIV disease in Latin America","volume":"16","author":"M Nacher","year":"2020","journal-title":"PLoS Pathog"},{"issue":"1","key":"pntd.0013527.ref036","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0010960","article-title":"The \u201cHistoplasmosis Porto Alegre manifesto\u201d-Addressing disseminated histoplasmosis in AIDS","volume":"17","author":"AC Pasqualotto","year":"2023","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0013527.ref037","unstructured":"Caceres DH, Adenis A, Vicente J, Souza B, Gomez BL, Cruz KS, et al. The Manaus Declaration: Current Situation of Histoplasmosis in the Americas, Report of the II Regional Meeting of the International Histoplasmosis Advocacy Group. 2019."}],"updated-by":[{"DOI":"10.1371\/journal.pntd.0013527","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,9,22]],"date-time":"2025-09-22T00:00:00Z","timestamp":1758499200000}}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013527","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,22]],"date-time":"2025-09-22T17:50:48Z","timestamp":1758563448000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013527"}},"subtitle":[],"editor":[{"given":"Joshua","family":"Nosanchuk","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,9,17]]},"references-count":37,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9,17]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0013527","relation":{},"ISSN":["1935-2735"],"issn-type":[{"value":"1935-2735","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,17]]}}}