Hyperthyroidism Secondary to Disseminated Mucormycosis in a Child with Acute Lymphoblastic Leukemia: Case Report and a Review of Published Reports

Thyroiditis due to fungal infection is an extremely rare cause of hyperthyroidism. The most common etiological factor of thyroiditis is Aspergillus. Infections due to members of the Mucorales have been an increasing clinical problem in recent years, and the prognosis in generalized infections due to those fungi is usually very poor. No hyperthyroidism in a child with thyroiditis due to mucormycosis has been reported in the literature so far. We describe a clinical course of generalized mucormycosis with thyroid involvement in a 12-year-old girl treated for acute lymphoblastic leukemia. The child underwent a hyperthyroidism connected with thyroid involvement due to a fungal process. The diagnosis was based on the clinical signs, laboratory findings and typical ultrasound scan; however, later attempt to amplify the fungi DNA from the tissue block has failed. The child died because of multiorgan failure due to general fungal infection 49 days after the invasive fungal infection was diagnosed. The generalized mucormycosis is always connected with poor prognosis and the mortality is high.     

Acute thyroiditis in a child: misleading result of fine-needle aspiration biopsy

We report a case of acute thyroiditis in a 6-year-old girl, whose initial borderline clinical and sonographic data, coupled with the absence of leucocytes and bacteria on the fine-needle aspiration biopsy, led to the reversal of the initial diagnostic impression of acute thyroiditis and the institution of an inappropriate glucocorticoid treatment. Since both diseases are rare in the paediatric age group and therapy is completely different, we conclude that in borderline cases careful clinical observation and the response to the initial antibiotic therapy should be considered more reliable than any single morphologic or microbiologic result. We also suggest that acute bacterial thyroiditis could be usefully classified into two forms, suppurative and non-suppurative.     

Recurrent Acute Suppurative Thyroiditis Attributable to a Piriform Sinus Fistula in an Adult

ObjectiveTo report a case of recurrent acute suppurative thyroiditis (AST) caused by a piriform sinus fistula (PSF).MethodsWe review the related literature and describe the clinical presentation, diagnostic evaluation, and management of a patient with recurrent AST due to PSF.ResultsA 50-year-old woman presented with recurrent episodes of pain and swelling in the left anterior neck area and odynophagia. The initial episode, 1 year previously, lasted for 1 month, and her condition improved with a short course of prednisone. Subsequently, the neck pain recurred and extended upward to both sides of the neck. She was suspected of having thyroiditis and was treated with prednisone for 6 weeks, but the symptoms persisted. Physical examination showed tenderness and induration of the skin over the left lobe of the thyroid. Ultrasonography disclosed an ill-defined solid-cystic area in the left thyroid lobe. Fine-needle aspiration cytology revealed acute inflammation, consistent with an infected cyst. A computed tomographic scan of the neck showed obscuration of the fat planes involving the left strap musculature and evidence suggestive of microabscesses. Prolonged intravenous antibiotic treatment ultimately alleviated the symptoms. Direct laryngoscopy revealed a fistula extending anteriorly from the apex of the piriform sinus. The patient underwent complete fistulectomy and left thyroid lobectomy and was asymptomatic on followup.ConclusionPSF should be suspected as a cause of recurrent AST. Absence of fever, toxemia, and local erythema does not rule out the condition. Unresponsiveness to corticosteroid therapy in thyroiditis should suggest the diagnosis. Complete fistulectomy and resection of the involved thyroid lobe result in permanent cure. (Endocr Pract. 2007;13:662-666)     

Acute suppurative thyroiditis in appearance of unusual neck mass

We report on three adult cases of acute suppurative thyroiditis due to infection through a piriform sinus fistula. In these cases, the lesion did not exhibit the clinical symptoms characteristic of acute suppuration, but appeared as an unusual neck mass. Repeated barium meal roentgenograms, however, demonstrated the internal fistula in two of the three cases. Acute suppurative thyroiditis may not be so rare even in adults. When acute suppurative thyroiditis occurs in adults with scanty symptoms of acute suppuration, the piriform sinus fistula could easily go undetected. Recognition of acute suppurative thyroiditis in adults per se seems to be important for correct diagnosis.     

Suppurative thyroiditis caused by Salmonella enteritidis

Bacterial thyroiditis is a rare disease, and one of which the clinical symptoms and signs are frequently misleading. On the other hand, prompt diagnosis is crucial for successful treatment. We report the case of an 82 year-old man with diabetes mellitus type 2 and a history of steroid treatment who presented with severe odynophagia and dysphagia associated with fever, chills, sore throat and right ear pain. Based on the clinical picture, radiological studies, thyroid cytology, blood and thyroid aspirate culture, suppurative thyroiditis caused by Salmonella enteritidis was diagnosed. The patient was successfully treated with antibiotics and surgical drainage.     

Micosis cutánea por Curvularia pallescens en un paciente trasplantado pulmonar: primer caso descrito en España

BackgroundCurvularia is a filamentous dematiaceous fungus increasingly recognized as a pathogen in immunocompromised patients. The most common clinical entities associated with this fungus are allergic sinusitis, cutaneous infection and keratitis. In this article, a report on the first clinical case of Curvularia pallescens cutaneous infection in Spain and its treatment is described.Case reportA 68 year-old man with a history of lung transplantation presented to Dermatology Unit due to a skin lesion in the knee that had been evolving for 6 months. A skin biopsy was performed for its study. In the histopathological study, an intense and non-specific inflammatory reaction in the dermis was observed, and with Grocott stain and periodic acid Schiff abundant septate hyphae and spores were found in the dermis. The culture of the sample revealed a filamentous fungus whose microscopic examination allowed to identify the genus as Curvularia. Using MALDI-TOF mass spectrometry and molecular identification, the fungus was finally identified as Curvularia pallescens. The patient underwent surgical resection of the lesion and was treated with posaconazole, evolving favorably.ConclusionsThe species of Curvularia should be considered causal agents of fungal skin infections in immunosuppressed patients. This clinical case, which showed good clinical response after surgical resection and treatment with posaconazole, is the first described in Spain due to this species.     

Thyroid Tuberculosis With Abnormal Thyroid Function-Case Report And Review Of The Literature

ObjectiveTo report an extremely rare case of thyroid tuberculosis (TT) with abnormal thyroid function and to review the related literature.MethodsWe present the patient's history, clinical findings, laboratory test results, imaging examinations, cytological data, management, and follow-up. In addition, we perform a review of the previously published cases of TT and give special attention to those with hypothyroidism.ResultsA 45-year-old Indian man presented to the outpatient clinic with neck swelling and respiratory and constitutional symptoms. Cervical ultrasound revealed a thyroid nodule and a necrotic right cervical adenopathy. Fine-needle aspiration cytology (FNAC) was performed and purulent material was removed from thyroid and lymph node. In both specimens, the culture was positive for Mycobacterium tuberculosis complex, and a cytological examination revealed epithelioid cell granulomas and necrosis. Mycobacterium tuberculosis complex was also identified by sputum culture. Antibiotic testing revealed sensitivity to all first-line drugs. A diagnosis of disseminated tuberculosis with thyroid and cervical lymph node involvement was made. Thyroid function was consistent with subclinical hyperthyroidism that subsequently evolved to hypothyroidism, requiring thyroid hormone replacement, and reflected tuberculous thyroiditis. Anti-tuberculosis drugs were started with good therapeutic response.ConclusionTT is a rare condition and its association with thyroid function abnormalities is even rarer. To our knowledge this is the third report of hypothyroidism related to TT and the first to identify a period of hyperthyroidism preceding hypothyroidism. Despite its rarity, TT should be considered in the differential diagnosis of neck mass. FNAC is a useful procedure and thyroid function should be monitored.     

Level of redox potential as a possible contributing influence in the pathogenicity of oral anaerobes

Dental plaque anaerobes may be associated with the etiology of periodontal disease. This has created an interest in the potential pathogenicity of oral anaerobes. We compared the metabolic activity of anaerobic corynebacteria (C. parvum, C. anaerobium) and corresponding aerobic species (C. diphtheriae, C. xerosis). The anaerobes exhibited lower levels of growth rate, m-RNA half-life and ribosomal efficiency but much higher levels of RNA synthesis, ranging from 5 to 10 fold over the aerobes. We further examined these anaerobes, plusActinomyces naeslundi N16 (isolated from the anaerobic region of periodontally-diseased tissues), for the influence of redox potential on RNA level and antigenic function. Notable increases in RNA were found at specific Eh levels; the extent and direction of the changes varied with the different organisms. This environmental feature appeared to effect corresponding changes in agglutinability and PCA reactivity with antisera against the anaerobes cultured at different redox potentials. For example, while antisera against certain organisms (C. parvum, A. naeslundi) cultured under the most reduced conditions showed an intense PCA reaction, other antisera against the same organism cultured under less reduced conditions were non-reactive. Hence, alterations in redox potential may lead to altered metabolism and to altered antigenicity. Our results imply such a microbial response to environmental stress.     

Molecular Confirmation of Bacillus Calmette Guerin Vaccine Related Adverse Events among Saudi Arabian Children

Background

Bacillus Calmette Guerin (BCG) is the only available vaccine for tuberculosis (TB). Low grade complications in healthy recipients and disseminated vaccine associated complications among immuno-suppressed individuals were noticed globally after administration. Recently a series of clinically suspected BCG associated suppurative and non-suppurative lymphadenitis cases were reported from different regions of Saudi Arabia. However a molecular confirmative analysis was lacking to prove these claims.

Methodology

During 2009–2010, 42 Mycobacterium bovis BCG suspected clinical isolates from children diagnosed with suppurative lymphadenitis from different provinces of the country were collected and subjected to 24 loci based MIRU-VNTR typing, spoligotyping and first line anti-TB drugs susceptibility testing.

Principal Findings

Of the total 42 cases, 41 (97.6%) were Saudi nationals and particularly male (64.3%). Majority of the cases were aged below 6 months (83.3%) with a median of age 4 months. All the enrolled subjects showed left axillary mass which suppurated in a median of 4 months after vaccination. Among the study subjects, 1 (2.4%) case was reactive to HIV antigen and 2 (4.8%) case had severe combined immunodeficiency. Genotyping results showed that, 41 (97.6%) isolates were identical to the vaccine strain Danish 1331 and one to Tokyo 172-1. Phylogenetic analysis revealed all the Danish 1331 isolates in a single cluster.

Conclusion

Elevated proportion of suppurative lymphadenitis caused by M. bovis BCG reported in the country recently is majorly related to the vaccine strain Danish 1331. However lack of nationwide data on real magnitude of BCG related adverse events warrants population centric, long term future studies.     

Human urogenital myiasis caused by the ‘rat-tailed’ larvae of Palpada scutellaris (Fabricius, 1805) in Santander,eastern Colombia: A case report

The Palpada genus, which belongs to the Diptera order (family, Syrphidae), has been rarely reported to cause accidental myiasis in humans. Herein, we report the first case of genitourinary myiasis caused by a larva of the Palpada genus in a 9-year-old girl from Colombia. The girl, who resided in a rural area in the municipality of Floridablanca, Santander, near Bucaramanga city, in eastern Colombia, presented with lower abdominal pain accompanied by oliguria, followed by the subsequent elimination of a larva through the urine. The next day, the patient visited a primary healthcare centre, and no signs or symptoms were observed on clinical examination. Haematological analysis showed high plateletcrit levels and platelet large cell counts. The results of the urine test revealed a decrease in specific gravity and a slight increase in bacterial content and mucus. DNA barcoding analyses showed that the etiological agent corresponded to a third instar larva of the Palpada scutellaris species. This is the first case to report genitourinary myiasis caused by larvae of the genus Palpada in humans. However, we believe that additional cases might be accurately detected if adequate tests are performed to confirm the clinical and molecular features associated with this infection.     

Comparative Pathogenicity of Actinomyces naeslundii and Actinomyces israelii

Typical actinomycosis has been produced in mice following single intraperitoneal injections of saline suspensions of Actinomyces israelii and A. naeslundii. A. israelii produced infections in 95.8% of the animals inoculated. A. naeslundii, generally considered to be a saprophytic organism, produced lesions in 89.7% of the inoculated animals. The finding that A. naeslundii produced lesions in mice similar to those produced by A. israelii suggests that A. naeslundii has similar pathogenic potential for man. The isolation of A. naeslundii from suppurative lesions of man also supports this conclusion.     

Distal Lateral Subungual Onychomycosis Owing to <Emphasis Type="Italic">Tritirachium oryzae</Emphasis>: A Bystander or Invader?

The genus Tritirachium is a mitosporic fungus which inhabits in soil and decaying plant material and also a notable insect pathogen. Human infections with Tritirachium species though rare were previously reported to cause corneal ulcers, otomycosis, onychomycosis, and dermatomycosis of the scalp and hence may be considered as a potential pathogen. Here we report a case of distal lateral subungual onychomycosis involving right great toenail in a 22-year-old female, wherein direct potassium hydroxide preparations, fungal cultures, and molecular sequencing of the isolate established Tritirachium oryzae as the etiological agent. Antifungal susceptibility performed by the microbroth technique of CLSI revealed increased MICs to amphotericin B and low MICs to azoles and echinocandins. The case was managed with surgical nail avulsion followed by topical application of 2% ketoconazole cream resulting regrowth of normal nail. To the best of our knowledge, this is the first report of non-dermatophytic mold T. oryzae causing onychomycosis in India.     

A Case of Riedel’s Thyroiditis Treated with Tamoxifen: Another Successful Outcome

ObjectiveTo report a case of Riedel’s thyroiditis, which was successfully treated with tamoxifen.MethodsWe present the clinical, laboratory, and imaging findings and describe the clinical course of a patient with Riedel’s thyroiditis.ResultsA 40-year-old woman presented with hypothyroidism and a large goiter, which was unresponsive to hormone replacement therapy. Magnetic resonance imaging confirmed the presence of an enlarged thyroid gland, more pronounced on the right than on the left. The patient had progressive discomfort attributable to compressive symptoms in the neck. Surgical exploration of the neck disclosed a hard, immobile thyroid mass, which could not be resected because of adherence to surrounding structures. Biopsy of the thyroid and of the muscles of the neck revealed Riedel’s thyroiditis. Treatment with tamoxifen, in a dosage of 20 mg twice a day for more than 1½ years, completely resolved the neck mass (substantiated by follow-up magnetic resonance imaging) and relieved the signs and symptoms of compression of the neck.ConclusionTamoxifen treatment is effective in resolving the mass and compression in Riedel’s thyroiditis. (Endocr Pract. 2004;10:483-486)     

High Pulmonary Levels of IL-6 and IL-1β in Children with Chronic Suppurative Lung Disease Are Associated with Low Systemic IFN-γ Production in Response to Non-Typeable Haemophilus influenzae

Non-typeable Haemophilus influenzae (NTHi) is commonly associated with chronic suppurative lung disease in children. We have previously shown that children with chronic suppurative lung disease have a reduced capacity to produce IFN-γ in response to NTHi compared with healthy control children. The aim of this study was to determine if deficient NTHi-specific IFN-γ production is associated with heightened systemic or airway inflammation. We measured a panel of cytokines (IFN-γ, IL-1β, IL-6, IL-8, IL-12 p70), antimicrobial proteins (LL-37, IP-10) as well as cellular and clinical factors associated with airway and systemic inflammation in 70 children with chronic suppurative lung disease. IFN-γ was measured in peripheral blood mononuclear cells challenged in vitro with live NTHi. Regression analysis was used to assess the association between the systemic and airway inflammation and the capacity to produce IFN-γ. On multivariate regression, NTHi-specific IFN-γ production was significantly negatively associated with the BAL concentrations of the inflammatory cytokines IL-6 (β=-0.316; 95%CI -0.49, -0.14; p=0.001) and IL-1β (β=-0.023; 95%CI -0.04, -0.01; p=0.001). This association was independent of bacterial or viral infection, BAL cellularity and the severity of bronchiectasis (using modified Bhalla score on chest CT scans). We found limited evidence of systemic inflammation in children with chronic suppurative lung disease. In summary, increased local airway inflammation is associated with a poorer systemic cell-mediated immune response to NTHi in children with chronic suppurative lung disease. These data support the emerging body of evidence that impaired cell-mediated immune responses and dysregulated airway inflammation may be linked and contribute to the pathobiology of chronic suppurative lung disease.     

IL-1RN VNTR polymorphism and genetic susceptibility to cervical cancer in Portugal

Human Papillomavirus infection is considered as the main etiological factor of cervical cancer (ICC), although, the role of host genetic factors in ICC susceptibility has been increasing. Immunological response is crucial for the prevention of viral associated diseases. Interleukin 1 receptor antagonist (IL-1RN) is considered to be an important regulator of host immunity and several studies have shown a potential role of a 86?bp VNTR polymorphism within intron 2 of the IL-1RN gene in host immune response variability. We investigated the role of this polymorphism in cervical cancer development in Portugal with a case–control study developed with peripheral blood samples from 196 healthy women and 340 women with cervical lesions from the Northern Region of Portugal. We observed that IL-1RN Allele 2 homozygosis was significantly higher in cases than in controls. In fact, IL-1RN A2*A2 homozygous revealed to be associated with an increased risk of HSIL?+?ICC (OR?=?1.90; 95?% IC 1.13–3.21; p?=?0.015). Furthermore, we also observed that median age of onset of HSIL?+?ICC was significantly different (46.0 vs 52.0) in IL-1RN A2*A2 homozygous comparing to non-A2*A2 (p?=?0.028). Our results indicated that IL-1RN A2 allele is associated with an increased susceptibility to cervical cancer development, probably by increasing predisposition to shorter immune responses.     

Cyberlindnera fabianii: primer aislamiento clínico en Chile

BackgroundAlthough considered an unusual etiological agent, Cyberlindnera (Candida) fabianii has been related to septicemia in several reports in recent years. Its doubtful or uncertain identification when using tests such as CHROMagar Candida, API® Candida, API® ID32C or VITEK® MS, leads to an underestimation of the cases produced by this yeast.AimsTo report the first isolation of C. fabianii in Chile and its identification.MethodsThe sequencing of the internal transcribed spacer region (ITS) was performed. Antifungal susceptibility profiles were obtained by means of the broth microdilution technique.ResultsThe identification was only reached by sequencing the ITS regions, which shows the limited usefulness of the conventional techniques in the identification of some yeast species. A dendrogram shows the phylogenetic relationship of the isolated strain with some other yeast species.ConclusionIn the identification of fastidious microorganisms or microorganisms whose identification is not completely reliable when using classical or even advanced methodologies, such as mass spectrometry, sequencing techniques are essential.     

Management of Thyrotoxicosis: Preconception,Pregnancy, and the Postpartum Period

Objective: To review the diagnosis and management of thyrotoxicosis in women who are preconception, pregnant, and in the postpartum period.Methods: Literature review of English-language papers published between 1980 and 2018.Results: Overt thyrotoxicosis occurs in 0.2% of pregnancies and subclinical thyrotoxicosis in 2.5%. Hyperthyroidism in women of childbearing age most frequently is caused by Graves disease (GD). Gestational thyrotoxicosis, transient human chorionic gonadotropin (hCG)-mediated hyperthyroidism, may develop in the first trimester. In the first year following delivery, postpartum thyroiditis, which frequently includes a thyrotoxic phase, occurs in 5% of women. Hyperthyroidism from nodular autonomy is uncommon in women of childbearing age. It is essential to understand the underlying etiology for thyrotoxicosis in order to recommend appropriate treatment. Gestational thyrotoxicosis requires supportive care, without antithyroid drug therapy. GD may be treated with antithyroid drugs, radioactive iodine, or thyroidectomy. Pregnancy, plans for pregnancy, and lactation have important implications for the choice of GD treatment. When thyrotoxicosis presents following delivery, postpartum thyroiditis must be differentiated from GD.Conclusion: The diagnosis and management of thyrotoxicosis in the peripregnancy period present specific challenges. In making management decisions, it is essential to weigh the risks and benefits of treatments not just for the mother but also for the fetus and for breastfed infants. A team approach to management is critical, with close collaboration among endocrinologists, maternal-fetal medicine specialists, and neonatologists.Abbreviations: GD = Graves disease; hCG = human chorionic gonadotropin; MMI = methimazole; PPT = postpartum thyroiditis; PTU = propylthiouracil; T3 = triiodothyronine; T4 = thyroxine; TBG = thyroxine-binding globulin; TRAb = TSH receptor antibody; TSH = thyroid-stimulating hormone     

Molecular Detection of Rickettsia typhi in Cats and Fleas

Background

Rickettsia typhi is the etiological agent of murine typhus (MT), a disease transmitted by two cycles: rat-flea-rat, and peridomestic cycle. Murine typhus is often misdiagnosed and underreported. A correct diagnosis is important because MT can cause severe illness and death. Our previous seroprevalence results pointed to presence of human R . typhi infection in our region; however, no clinical case has been reported. Although cats have been related to MT, no naturally infected cat has been described. The aim of the study is to confirm the existence of R . typhi in our location analyzing its presence in cats and fleas.

Methodology/Principal Findings

221 cats and 80 fleas were collected from Veterinary clinics, shelters, and the street (2001-2009). Variables surveyed were: date of collection, age, sex, municipality, living place, outdoor activities, demographic area, healthy status, contact with animals, and ectoparasite infestation. IgG against R . typhi were evaluated by indirect immunofluorescence assay. Molecular detection in cats and fleas was performed by real-time PCR. Cultures were performed in those cats with positive molecular detection. Statistical analysis was carried out using SPSS. A p < 0.05 was considered significant.Thirty-five (15.8%) cats were seropositive. There were no significant associations among seropositivity and any variables. R . typhi was detected in 5 blood and 2 cultures. High titres and molecular detection were observed in stray cats and pets, as well as in spring and winter. All fleas were Ctenocephalides felis. R . typhi was detected in 44 fleas (55%), from shelters and pets. Co-infection with R . felis was observed.

Conclusions

Although no clinical case has been described in this area, the presence of R . typhi in cats and fleas is demonstrated. Moreover, a considerable percentage of those animals lived in households. To our knowledge, this is the first time R . typhi is detected in naturally infected cats.     

Destructive Thyroiditis Followed by Hypothyroidism Associated with Infliximab Therapy

ObjectiveTo present the rare case of a patient who developed destructive thyroiditis accompanied by transient thyrotoxicosis resulting from infliximab therapy for the treatment of psoriasis.MethodsThe clinical presentation and management of a case with infliximab-associated thyroiditis is described with a brief review of the literature.ResultsA 57-year-old male who suffered from psoriasis was treated with infliximab therapy for 4 years. Thyroid function tests were normal before infliximab therapy. When the patient presented in our clinic, he had thyrotoxicosis and was using propylthiouracil. A 99m Technetiumpertechnetate thyroid scintigraphy scan showed no visualization of either thyroid lobe or decreased thyroid iodine uptake. Thyroid-stimulating hormone (TSH) receptor antibody, thyroid peroxidase antibody (anti-TPO Ab) and thyroglobulin antibody (anti-Tg Ab) were negative. Thyroid ultrasonography revealed a heterogeneous thyroid gland without nodules. After stopping propylthiouracil therapy, we advised monitoring of his thyroid function tests in the following weeks, and infliximab therapy for psoriasis was continued. Four weeks later, his thyroid function tests showed an elevated TSH level with normal levels of free triiodothyronine and thyroxine (FT3 and FT4, respectively), and levothyroxine treatment was administered to the patient. Thyroid function tests normalized after levothyroxine treatment. One year later, infliximab therapy was stopped because of clinical remission. Simultaneously, levothyroxine treatment was also stopped. His thyroid function tests were normal 6 weeks after the cessation of levothyroxine treatment.ConclusionTo our knowledge, the present report is the third infliximab-associated thyroid disorder case. Periodic follow-up of thyroid function tests is necessary during infliximab therapy. (Endocr Pract. 2014;20:e207-e210)     

Prevalence of mycoplasmas in external ear canal of goats: Influence of the sanitary status of the herd

A study was carried out in 15 French goat herds to assess the presence of mycoplasmas in the external ear canal of goats and to estimate the association between the ear isolates (highly pathogenic or non-pathogenic) and the status of the herds with respect to the mycoplasma infections. In each herd, 20 clinically normal goats were investigated once and mycoplasma isolates were identified by MF-dot tests. Influence of herd status on the proportion of animals carrying highly pathogenic species of mycoplasmas was evaluated by calculating the Odds Ratios. The present study gave first of all an estimate of the relative importance of mycoplasma carriage in healthy French dairy goat herds. The species isolated were MmmLC, Mcc, Ma, Mp (considered as highly pathogenic) and My and Mc (non-pathogenic species). Carriage often involve several strains and/or species in the same ear canal. The highly pathogenic species were significantly more frequent in the herds with prior history of mycoplasma infection. This asymptomatic carrier state makes the sanitary status of a herd ambiguous and represents a risk of subsequent propagation of the etiological agents, during close physical contact or by intervention of vectors (mites).