{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T15:22:35Z","timestamp":1785424955012,"version":"3.56.0"},"reference-count":48,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Victor Babe\u015f University of Medicine and Pharmacy"},{"id":[{"id":"https:\/\/ror.org\/00afdp487","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Background: Giant cell myocarditis (GCM) is a rare condition with an incompletely understood immune pathogenesis, characterized by inflammatory damage to the myocardium and the presence of multinucleated giant cells on histopathological examination. The frequently fulminant and severe course requires rapid intervention for a correct diagnosis and the initiation of immunosuppressive therapy, which is often life-saving. Materials and methods: This article contains information from observational studies and case reports, systematically collected from prestigious publications such as JACC, NEJN, ESC, JCC, Heliyon, and Cureus found in the PubMed and ClinicalTrials.gov databases. Thus, 25 patients diagnosed with giant cell myocarditis between March 2019 and May 2025 were analyzed, with a focus not only on the initial clinical evolution, mortality incidence, and the need for heart transplantation but also on the incidence of major complications such as cardiogenic shock and malignant rhythm and conduction disorders refractory to drug treatment. These parameters were studied according to certain intrinsic factors that cannot be influenced, such as age at onset, gender, and associated pathology of the patient, as well as extrinsic factors that can be influenced, such as the time of diagnosis and the start of immunosuppressive therapy. The results obtained were compared with those in the literature from previous years, considering the limitations of the current study. Results: The selected patients were 13 women (52%) and 12 men (48%), mostly from the US and Japan, aged between 22 and 76 years, with an average age of 44.92 years. An associated autoimmune pathology was found in 40% of patients in this group, and previous cardiovascular pathology in 28%. Only 8% had a history of GCM. The clinical onset of new-onset heart failure, refractory to usual therapy, with progressive dyspnea as the cardinal symptom was found in 12 patients, representing 48% of cases; palpitations as an expression of rhythm or conduction disorders were found in five patients, representing 20%; precordial discomfort to precordial pain accompanied or not by ST-T segment changes was present in four patients, representing 16%; and general signs and symptoms or those of other organs were present in three (12%) cases. The diagnosis was made by histological examination of the biopsy fragment obtained by endomyocardial biopsy or from the myocardial fragment obtained during the implantation of mechanical cardiovascular support devices and, less frequently, on the explanted heart and at autopsy. In terms of progression, of the 25 patients, four (16%) died, four (16%) required heart transplantation, and 16 (64%) had a severe progression with cardiogenic shock, which required mechanical circulatory support in 11 (44%) cases. The outcome was mainly influenced by the early diagnosis and administration of immunosuppressive medication, but also by the age of the patients and associated chronic diseases. Conclusions: Giant cell myocarditis is a serious condition that, in the absence of rapid diagnosis and appropriate immunosuppressive therapy, has a fulminant, often fatal course. Clinical suspicion of giant cell myocarditis remains important in the initial diagnosis. Raising this suspicion, together with modern and improved paraclinical investigations compared to previous years, has led to faster diagnosis and administration of immunosuppressive therapy in this pathology. Histological examination remains the gold standard for final diagnosis, but it should be noted that it may be non-diagnostic. In the face of a strong suspicion of giant cell myocarditis, the best approach is to start immunosuppressive therapy and monitor the patient\u2019s progress. Immunosuppressive treatment remains decisive in influencing the evolution of this condition, both through prompt administration and through the adaptation of therapeutic regimens to the evolution of patients. A more detailed understanding of the immune-mediated pathogenesis of GCM and the identification of clinical risk factors for unfavorable short- and long-term outcomes may enable earlier risk stratification and the development of more targeted, individualized therapeutic strategies.<\/jats:p>","DOI":"10.3390\/life16040575","type":"journal-article","created":{"date-parts":[[2026,4,2]],"date-time":"2026-04-02T14:09:54Z","timestamp":1775138994000},"page":"575","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Impact of Early Diagnosis and Immunosuppressive Therapy on Giant Cell Myocarditis Outcomes: A Review"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2824-7182","authenticated-orcid":false,"given":"Nilima Rajpal","family":"Kundnani","sequence":"first","affiliation":[{"name":"Department VI-Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"},{"name":"Research Centre of Timisoara, Institute of Cardiovascular Diseases, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5724-8603","authenticated-orcid":false,"given":"Abhijit","family":"Kumar","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Kalyani 741245, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0865-0054","authenticated-orcid":false,"given":"Abhinav","family":"Sharma","sequence":"additional","affiliation":[{"name":"Department VI-Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"},{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Berceanu Vaduva Marcel","family":"Mihai","sequence":"additional","affiliation":[{"name":"Department XVI-Orthopedics-Traumatology, Urology and Medical Imaging, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristina","family":"Diana Ardelean","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucretia","family":"Marin-Bancila","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mihaela","family":"Valcovici","sequence":"additional","affiliation":[{"name":"Department VI-Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Codrina","family":"Levai","sequence":"additional","affiliation":[{"name":"Discipline of Medical Communications, Department 2-Microscopic Morphology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"},{"name":"Research Center for Medical Communication, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2881-878X","authenticated-orcid":false,"given":"Adela","family":"Iancu","sequence":"additional","affiliation":[{"name":"IInd Family Medicine Department, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8619-0479","authenticated-orcid":false,"given":"Ciprian Ilie","family":"Rosca","sequence":"additional","affiliation":[{"name":"Department V, Internal Medicine I\u2014Discipline of Medical Semiology I, Center of Advanced Research in Cardiology and Hemostasology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1807","DOI":"10.1161\/CIRCULATIONAHA.106.174287","article-title":"Contemporary Definitions and Classification of the Cardiomyopathies: An American Heart Association Scientific Statement","volume":"113","author":"Maron","year":"2006","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1161\/01.CIR.93.5.841","article-title":"Report of the 1995 World Health Organization\/International Society and Federation of Cardiology Task Force on the Definition and Classification of cardiomyopathies","volume":"93","author":"Richardson","year":"1996","journal-title":"Circulation"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1053\/sarh.2000.8367","article-title":"Giant cell myocarditis: Most fatal of autoimmune diseases","volume":"30","author":"Rosenstein","year":"2000","journal-title":"Semin. Arthritis Rheum."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1016\/j.celrep.2019.06.007","article-title":"The Cardiac Microenvironment Instructs Di-Vergent Monocyte Fates and Functions in Myocarditis","volume":"28","author":"Hou","year":"2019","journal-title":"Cell Rep."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1526","DOI":"10.1056\/NEJMra0800028","article-title":"Myocarditis","volume":"360","author":"Cooper","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1016\/j.jacc.2020.11.074","article-title":"Management of Patients with Giant Cell Myocarditis: JACC Review Topic of the Week","volume":"77","author":"Bang","year":"2021","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1429","DOI":"10.5858\/arpa.2016-0068-RS","article-title":"Giant Cell Myocarditis: A Brief Review","volume":"140","author":"Xu","year":"2016","journal-title":"Arch. Pathol. Lab. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"306","DOI":"10.21470\/1678-9741-2017-0242","article-title":"Left Atrial Giant Cell Myocarditis Presenting as a Tumor: First-in-Man Case Report","volume":"33","author":"Tanyeli","year":"2018","journal-title":"Braz. J. Cardiovasc. Surg."},{"key":"ref_9","first-page":"40439","article-title":"Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review","volume":"15","author":"Naseeb","year":"2023","journal-title":"Cureus"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1535","DOI":"10.1016\/j.amjcard.2008.07.041","article-title":"Usefulness of Immuno-Suppression for Giant Cell Myocarditis","volume":"102","author":"Cooper","year":"2008","journal-title":"Am. J. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1860","DOI":"10.1056\/NEJM199706263362603","article-title":"Idiopathic Giant-Cell Myocarditis\u2013Natural History and Treatment. Multicenter Giant Cell Myocarditis Study Group Investigators","volume":"336","author":"Cooper","year":"1997","journal-title":"N. Engl. J. Med."},{"key":"ref_12","first-page":"224","article-title":"Sudden Cardiac Death Due to Ventricular Fibrillation in a Case of Giant Cell Myocarditis","volume":"21","author":"Umei","year":"2020","journal-title":"J. Cardiol. Cases"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1163","DOI":"10.1517\/14728222.2011.601294","article-title":"Autoimmune Giant Cell Myocarditis: Clinical Characteristics, Experimental Models, and Future Treatments","volume":"15","author":"Suzuki","year":"2011","journal-title":"Expert Opin. Ther. Targets"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2320","DOI":"10.1002\/ehf2.13276","article-title":"Late gadolinium enhancement characteristics in giant cell myo-carditis","volume":"8","author":"Yang","year":"2021","journal-title":"ESC Heart Fail."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2291","DOI":"10.2169\/internalmedicine.1020-22","article-title":"Macrophage phagocytes amyloid fibrils in giant cell myocarditis","volume":"62","author":"Onoue","year":"2023","journal-title":"Intern. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2035","DOI":"10.2169\/internalmedicine.2471-18","article-title":"Successful Triple Combination Immunosuppressive Therapy with Prednisolone, Cyclosporine, and Mycophenolate Mofetil to Treat Recurrent Giant Cell Myocarditis","volume":"58","author":"Akita","year":"2019","journal-title":"Intern. Med."},{"key":"ref_17","first-page":"8","article-title":"Giant Cell Myocarditis with Central Diabetes Insipidus: A Case Report","volume":"21","author":"Yamaguchi","year":"2020","journal-title":"J. Cardiol. Cases"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"3165","DOI":"10.1002\/ehf2.12756","article-title":"Giant Cell Myocarditis in an Older Pa-Tient\u2014Reassessing the Threshold for Endomyocardial Biopsy","volume":"7","author":"Daud","year":"2020","journal-title":"ESC Heart Fail."},{"key":"ref_19","first-page":"315","article-title":"A Giant Mystery in Giant Cell Myocarditis: Navigating Diagnosis, Im-Munosuppression, and Mechanical Circulatory Support","volume":"7","author":"Fallon","year":"2020","journal-title":"ESC Heart Fail."},{"key":"ref_20","first-page":"186","article-title":"Management of a Patient Presenting with Giant Cell Myocarditis: A Case Report","volume":"21","author":"Patel","year":"2020","journal-title":"J. Cardiol. Cases"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2020238","DOI":"10.4322\/acr.2020.238","article-title":"Giant Cell Myocarditis Causing Sudden Death in a Patient with Sarcoidosis","volume":"10","author":"Ziegler","year":"2020","journal-title":"Autops. Case Rep."},{"key":"ref_22","first-page":"258","article-title":"A Case of Giant Cell Myocarditis Mim-Icking Cardiac Sarcoidosis Successfully Maintained by Prednisolone and Tacrolimus","volume":"27","author":"Tsuchiya","year":"2023","journal-title":"J. Cardiol. Cases"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1016\/j.cjco.2023.11.025","article-title":"A Case of Incidental Giant Cell Myocarditis Presenting after COVID-19 mRNA Vaccination","volume":"6","author":"Baweja","year":"2024","journal-title":"CJC Open"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1186\/s13019-023-02316-z","article-title":"Atrial Giant Cell Myocarditis with Preserved Left Ventricular Function: A Case Report and Literature Review","volume":"18","author":"Tang","year":"2023","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1093\/ehjcr\/ytab447","article-title":"Case Report: Heart Transplantation for Giant Cell Myocarditis in a Patient with Common Variable Immunodeficiency","volume":"5","author":"Franzon","year":"2021","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1080\/08998280.2021.1874775","article-title":"Giant cell myocarditis","volume":"34","author":"Gadela","year":"2021","journal-title":"Proc. Bayl. Univ. Med. Cent."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"ytac046","DOI":"10.1093\/ehjcr\/ytac046","article-title":"Successful Bridge to Recovery in Fulminant Giant Cell Myocarditis from Auto-Immune Disorders Including Myasthenia Gravis: Case Report","volume":"6","author":"Yagi","year":"2022","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1002\/ejhf.2590","article-title":"Giant Cell Myocarditis after First Dose of BNT162b2: A Case Report","volume":"24","author":"Hirsch","year":"2022","journal-title":"Eur. J. Heart Fail."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1093\/ehjcr\/ytac362","article-title":"Recurrent Giant Cell Myocarditis after Heart Transplant: A Case Report","volume":"6","author":"Frankel","year":"2022","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.jaccas.2021.11.013","article-title":"Fulminant Giant Cell Myocarditis Requiring Bridge with Mechanical Circulatory Support to Heart Transplantation","volume":"4","author":"Brailovsky","year":"2022","journal-title":"JACC Case Rep."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1093\/ehjcr\/ytaf248","article-title":"Fulminant Lymphocytic Myocarditis with Unusual Giant Cell De-Tection: A Case Report","volume":"9","author":"Sato","year":"2025","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_32","first-page":"82391","article-title":"Implantable Cardioverter-Defibrillators for Secondary Prevention in Giant Cell Myocarditis","volume":"17","author":"Shukla","year":"2025","journal-title":"Cureus"},{"key":"ref_33","first-page":"182","article-title":"Complete Remission of Giant Cell Myocarditis by Prednisolone Monotherapy","volume":"29","author":"Soma","year":"2024","journal-title":"J. Cardiol. Cases"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1093\/ehjcr\/ytae128","article-title":"Two Case Reports of Fulminant Giant Cell Myocarditis Treated with Rabbit Anti-Thymocyte Globulin","volume":"8","author":"Li","year":"2024","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"326","DOI":"10.1093\/ehjcr\/ytae326","article-title":"Giant Cell Myocarditis Attributable to Myositis: Therapeutic Management under Serial Biopsy","volume":"8","author":"Arai","year":"2024","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"32324","DOI":"10.1016\/j.heliyon.2024.e32324","article-title":"Temporary Mechanical Circulatory Support as Bridge to LVAD in Fulminant Giant Cell Myocarditis: A Case Report","volume":"10","author":"Zhang","year":"2024","journal-title":"Heliyon"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1093\/ehjcr\/ytaf276","article-title":"CMR and Biopsy in Giant Cell Myocarditis: Diagnostic Challenges and per-Spectives","volume":"9","author":"Gronwald","year":"2025","journal-title":"Eur. Heart J. Case Rep."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2895","DOI":"10.2169\/internalmedicine.9112-21","article-title":"Combination Immunosuppressive Therapy for Giant Cell Myocarditis","volume":"61","author":"Funaki","year":"2022","journal-title":"Intern. Med."},{"key":"ref_39","first-page":"125","article-title":"Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review","volume":"25","author":"Zappia","year":"2020","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_40","first-page":"173826","article-title":"Giant Cell Myocarditis: Not Always a Presentation of Cardiogenic Shock","volume":"2015","author":"Tompkins","year":"2015","journal-title":"Case Rep. Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/j.carpath.2011.10.001","article-title":"2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology","volume":"21","author":"Leone","year":"2012","journal-title":"Cardiovasc. Pathol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1016\/S0735-1097(02)02715-8","article-title":"A clinical and histopathologic comparison of cardiac sarcoidosis and idiopathic giant cell myocarditis","volume":"41","author":"Okura","year":"2003","journal-title":"JACC"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Osredkar, J., Bajri\u0107, A., Mo\u017eina, H., Lipar, L., and Jerin, A. (2024). Cardiac Troponins I and T as Biomarkers of Cardiomyocyte Injury\u2014Advantages and Disadvantages of Each. Appl. Sci., 14.","DOI":"10.3390\/app14146007"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"100118","DOI":"10.1016\/j.jtauto.2021.100118","article-title":"Diagnosis and Treatment of Eosinophilic Myocarditis","volume":"4","author":"Hong","year":"2021","journal-title":"J. Transl. Autoimmun."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"E1333","DOI":"10.21037\/jtd.2016.10.60","article-title":"Myocarditis with very high troponins: Risk stratification by cardiac magnetic resonance","volume":"8","author":"Janardhanan","year":"2016","journal-title":"J. Thorac. Dis."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Blyszczuk, P. (2019). Myocarditis in Humans and in Experimental Animal Models. Front. Cardiovasc. Med., 6.","DOI":"10.3389\/fcvm.2019.00064"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1016\/j.jacc.2017.04.025","article-title":"2017 ACC\/AHA\/HFSA focused update of the 2013 ACCF\/AHA guideline for the management of heart failure: A report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America","volume":"70","author":"Yancy","year":"2017","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1733","DOI":"10.1016\/j.amjcard.2015.03.023","article-title":"Long-term risk of recurrence, morbidity and mortality in giant cell myocarditis","volume":"115","author":"Maleszewski","year":"2015","journal-title":"Am. J. Cardiol."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/4\/575\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,2]],"date-time":"2026-04-02T14:21:46Z","timestamp":1775139706000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/4\/575"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,1]]},"references-count":48,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["life16040575"],"URL":"https:\/\/doi.org\/10.3390\/life16040575","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,1]]}}}