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Journal of Clinical Microbiology, February 2004, p. 645-651, Vol. 42, No. 2
0095-1137/04/$08.00+0 DOI: 10.1128/JCM.42.2.645-651.2004
Copyright © 2004, American
Society for
Microbiology. All Rights Reserved.
Serotypes, Virulence Genes, and Intimin Types of Shiga Toxin (Verotoxin)-Producing Escherichia coli Isolates from Cattle in Spain and Identification of a New Intimin Variant Gene (eae-
)
M. Blanco,1 J. E. Blanco,1 A. Mora,1 G. Dahbi,1 M. P. Alonso,1,2 E. A. González,1 M. I. Bernárdez,1 and J. Blanco1*
Laboratorio
de Referencia de E. coli, Departamento de Microbioloxía e
Parasitoloxía, Facultade de Veterinaria, Universidade
de Santiago de Compostela, 27002
Lugo,1
Unidade de
Microbioloxía, Complexo Hospitalario Xeral-Calde,
27004 Lugo, Spain2
Received 17 September 2003/
Accepted 29 October 2003
 |
ABSTRACT
|
|---|
A
total of 514 Shiga toxin-producing Escherichia coli (STEC)
isolates from diarrheic and healthy cattle in Spain were characterized
in this study. PCR showed that 101 (20%) isolates carried
stx1 genes, 278 (54%) possessed
stx2 genes, and 135 (26%) possessed both
stx1 and stx2. Enterohemolysin
(ehxA) and intimin (eae) virulence genes were
detected in 326 (63%) and in 151 (29%) of the isolates,
respectively. STEC isolates belonged to 66 O serogroups and 113 O:H
serotypes (including 23 new serotypes). However, 67% were of one
of these 15 serogroups (O2, O4, O8, O20, O22, O26, O77, O91, O105,
O113, O116, O157, O171, O174, and OX177) and 52% of the isolates
belonged to only 10 serotypes (O4:H4, O20:H19, O22:H8, O26:H11,
O77:H41, O105:H18, O113:H21, O157:H7, O171:H2, and ONT:H19). Although
the 514 STEC isolates belonged to 164 different seropathotypes
(associations between serotypes and virulence genes), only 12 accounted
for 43% of isolates. Seropathotype O157:H7
stx2 eae-
1 ehxA (46
isolates) was the most common, followed by O157:H7
stx1 stx2
eae-
1 ehxA (34 isolates), O113:H21
stx2 (25 isolates), O22:H8 stx1
stx2 ehxA (15 isolates), O26:H11
stx1 eae-ß1 ehxA (14
isolates), and O77:H41 stx2 ehxA (14
isolates). Forty-one (22 of serotype O26:H11) isolates had intimin
ß1, 82 O157:H7 isolates possessed intimin
1, three
O111:H- isolates had intimin type
2, one O49:H- strain showed
intimin type
, 13 (six of serotype O103:H2) isolates had
intimin type
and eight (four of serotype O156:H-) isolates
had intimin
. We have identified a new variant of the
eae intimin gene designated
(xi) in two isolates of
serotype O80:H-. The majority (85%) of bovine STEC isolates
belonged to serotypes previously found for human STEC organisms and
54% to serotypes associated with STEC organisms isolated from
patients with hemolytic uremic syndrome. Thus, this study confirms that
cattle are a major reservoir of STEC strains pathogenic for
humans.
 |
INTRODUCTION
|
|---|
Shiga toxin-producing Escherichia coli (STEC), also called
verotoxin-producing E. coli (VTEC), strains are the most
important recently emerged group of food-borne pathogens. These
bacteria can cause severe disease in humans, such as hemorrhagic
colitis and hemolytic uremic syndrome
(20,
29). Cattle, especially
young animals, have been implicated as a principal reservoir of STEC,
undercooked ground beef and raw milk being the major vehicles of
food-borne outbreaks (2,
5).
Human and bovine
STEC strains elaborate two potent phage-encoded cytotoxins called Shiga
toxins (Stx1 and Stx2) or verotoxins (VT1 and VT2)
(20,
29). In addition to toxin
production, another virulence-associated factor expressed by STEC is a
protein called intimin, which is responsible for intimate attachment of
STEC to intestinal epithelial cells, causing attaching and effacing
lesions in the intestinal mucosa
(16). Intimin is encoded
by the chromosomal gene eae, which is part of a pathogenicity
island termed the locus for enterocyte effacement
(19). Severe diarrhea
(specially hemorrhagic colitis) and hemolytic uremic syndrome were
closely associated with STEC types carrying the eae gene for
intimin (19,
29).
Differentiation
of intimin alleles represents an important tool for STEC typing in
routine diagnostics as well as epidemiological and clonal studies. The
C-terminal end of intimin is responsible for receptor binding, and it
has been suggested that different intimins may be responsible for
different host tissue cell tropism
(23,
32,
42). Intimin
type-specific PCR assays identified 14 variants of the eae
gene that encode 14 different intimin types and subtypes (
1,
2, ß1, ß2,
1,
2/
,
/
,
,
,
,
,
, µ,
)
(1,
6,
10,
18,
26,
36,
37,
42; Blanco et al.,
submitted for publication). A factor that may also affect the virulence
of STEC is the enterohemolysin, also called enterohemorrhagic E.
coli hemolysin, which is encoded by the ehxA gene
(35).
STEC strains
that cause human infections belong to a large number of O:H serotypes
(a total of 472 serotypes are listed at our website,
http://www.lugo.usc/ecoli).
Most outbreaks of hemorrhagic colitis and hemolytic uremic syndrome
have been attributed to strains of the enterohemorrhagic serotype
O157:H7 (5,
20). However, as STEC
non-O157 strains are more prevalent in animals and as contaminants in
foods, humans are probably more exposed to these strains. Infections
with some non-O157 STEC types, such as O26:H11 or H-, O91:H21 or H-,
O103:H2, O111:H-, O113:H21, O117:H7, O118:H16, O121:H19, O128:H2 or H-,
O145:H28 or H- and O146:H21 are frequently associated with severe
illness in humans, but the role of other non-O157 STEC types in human
disease needs further examination
(4,
5,
6,
11,
20). Although more than
400 different O:H serotypes of STEC have been isolated from cattle (a
total of 435 serotypes are listed at our website,
http://www.lugo.usc/ecoli),
there is a lack of information regarding associations between serotype,
intimin types, and virulence factor profiles among bovine STEC isolates
(12,
24,
34,
40).
Thus, the aim
of this study was to establish the serotypes, virulence genes, and
intimin types of STEC strains isolated from cattle to establish if
bovine STEC strains possess the same serotypes and virulence factor
profiles as STEC strains that cause human
infections.
 |
MATERIALS AND METHODS
|
|---|
E. coli isolates and control strains.
A total of 514
STEC isolates from diarrheic and healthy cattle in Spain were
characterized in this study. Only one isolate for each animal was
included. E. coli strains used as controls were EPEC-2348
(human, O127:H6, eae-
1), AEEC-IH2498a (human,
O125:H6, eae-
2), REPEC-RDEC-1 (rabbit, O15:H-,
eae-ß1), EPEC-359 (human, O119:H6,
eae-ß2), STEC-EDL933 (human, O157:H7,
stx1 stx2
eae-
1 ehxA), STEC-VTB308 (bovine, O111:H-,
stx1 eae-
2), STEC-TW07926 (human,
O111:H8, stx1 stx2
eae-
), EPEC-BP12665 (human, O86:H34,
eae-
), AEEC-6044/95 (human, O118:H5,
eae-
), STEC-VTB-286 (bovine, O103:H2,
stx1 eae-
), STEC-VTO-50 (ovine,
O156:H-, stx1 eae-
), AEEC-CF11201
(human, O125:H-, eae-
), AEEC-7476/96 (human, O145:H4,
eae-
), AEEC-68-4 (human, O34:H-,
eae-
), EPEC-373 (human, O55:H51,
eae-µ), AEEC-IH1229a (human, O10:H-,
eae-
), and K12-185 (negative for
stx1, stx2, eae and
ehxA). Strains were stored at room temperature in nutrient
broth with 0.75% of
agar.
Production and detection of Shiga toxins (verotoxins) in Vero and HeLa cells.
For production of Shiga toxins, one
loopful of each isolated colony was inoculated in 50-ml Erlenmeyer
flasks containing 5 ml of tryptone soy broth (pH 7.5) with mitomycin C
and incubated for 20 h at 37°C (shaken at 200 rpm)
and then centrifuged (6,000 x g) for 30 min at
4°C. The Vero and HeLa cell culture assays were performed with
nearly confluent cell monolayers grown in plates with 24 wells. At the
time of assay, the growth medium (RPMI with polymyxin sulfate) was
changed (0.5 ml per well) and 75 µl of undiluted culture
supernatant was added. Cells were incubated at 37°C in a
5% CO2 atmosphere and the morphological changes in
cells were observed after 24 and 48 h of incubation with a
phase contrast inverted microscope
(8,
9).
Detection of virulence genes by PCR.
Bacteria were harvested from tryptone
soy agar, suspended in 250 µl of sterile water, incubated at
100°C for 5 min to release the DNA, and centrifuged. The
supernatant was used in the PCR as described below. Base sequences and
predicted sizes of amplified products for the specific oligonucleotide
primers used in this study are shown in Table
1. The majority of oligonucleotide primers were designed by us according
to the nucleotide sequences of the virulence genes (Blanco et al.,
submitted). Multiplex PCR was used only for detection of
stx1 and stx2 genes. Isolates
positive for the eae gene with the EAE-1 and EAE-2 primers
were afterwards analyzed with all different variant
primers.
Amplification of bacterial DNA was performed with
30-µl volumes containing 7 µl of the prepared sample
supernatant; 150 ng of the oligonucleotide primers; 0.2 mM (each) dATP,
dGTP, dCTP, and dTTP; 10 mM Tris-HCl (pH 8.8); 1.5 mM MgCl2;
50 mM KCl; and 1 U of Biotaq DNA polymerase (Bioline, United Kingdom).
The conditions for the PCR were 94°C for 2 min for initial
denaturation of DNA within the sample, followed by 35 cycles of
94°C for 1 min (denaturation), 55°C to 66°C
(see Table 1) for 1 min
(primer annealing), and 72°C for 1 min (DNA synthesis)
performed with a thermal cycler (model PCR express; Hybaid, United
Kingdom). The amplified products were visualized by standard submarine
gel electrophoresis with 10 µl of the final reaction mixture on
a 2% agarose gel in TBE buffer (89 mM Tris, 89 mM boric acid,
2.5 mM EDTA). The samples were electrophoresed for 20 to 40 min at 130
V. Amplified DNA fragments of specific sizes were located by UV
fluorescence after being stained with ethidium bromide. Molecular size
markers (HaeIII digest of
x174DNA) (Promega) were
included in each gel
(10).
Sequencing of the eae genes.
The nucleotide sequence of the
amplification products was determined by the dideoxynucleotide
triphosphate chain termination method of Sanger, with the BigDye
Terminator v3.1 cycle sequencing kit with an ABI 3100 genetic analyzer
(Applied Bio-Systems).
Phylogenetic analyses.
Genetic distances
and phylogenetic trees of eae sequences were calculated and
constructed with the CLUSTAL W program
(38) included in the EMBL
software
(http://www.ebi.ac.uk/clustalw/).
Serotyping.
The determination of O and H antigens
was carried out by the method described by Guinée et al.
(14) employing all
available O (O1 to O181) and H (H1 to H56) antisera. All antisera were
obtained and absorbed with the corresponding cross-reacting antigens to
remove the nonspecific agglutinins. The O antisera were produced in the
Laboratorio de Referencia de E. coli, Departamento de
Microbioloxía e Parasitoloxía, Facultade de
Veterinaria, Universidade de Santiago de Compostela (Lugo, Spain,
http://www.lugo.usc.es/ecoli),
and the H antisera were obtained from the Statens Seruminstitut
(Copenhagen, Denmark).
Nucleotide sequence accession number.
The eae-
sequence
of strain B49 O80:H- was deposited in the European Bioinformatics
Institute (EMBL Nucleotide Sequence Database) and has been assigned
accession number
AJ582912.
 |
RESULTS
|
|---|
Virulence genes.
A total of 514 STEC
isolates from diarrheic and healthy cattle in Spain were characterized
in this study. PCR showed that 101 (20%) isolates carried
stx1 genes, 278 (54%) possessed
stx2 genes, and 135 (26%) possessed both
stx1 and stx2. Enterohemolysin
(ehxA) and intimin (eae) virulence genes were
detected in 326 (63%) and in 151 (29%) of the isolates,
respectively.
Serotypes and seropathotypes.
STEC isolates
belonged to 66 O serogroups and 113 O:H serotypes (including 23 new
serotypes). However, 67% were of one of these 15 serogroups (O2,
O4, O8, O20, O22, O26, O77, O91, O105, O113, O116, O157, O171, O174,
and OX177) and 52% of isolates belonged to only 10 serotypes
(O4:H4, O20:H19, O22:H8, O26:H11, O77:H41, O105:H18, O113:H21, O157:H7,
O171:H2, and ONT:H19). Although the 514 STEC isolates belonged to 164
different seropathotypes (associations between serotypes and virulence
genes), only 12 accounted for 43% of isolates (Table
2). Seropathotype O157:H7 stx2
eae ehxA (46 isolates) was the most common, followed by
O157:H7 stx1 stx2 eae
ehxA (34 isolates), O113:H21 stx2 (25
isolates), O22:H8 stx1 stx2
ehxA (15 isolates), O26:H11 stx1 eae
ehxA (14 isolates), and O77:H41 stx2
ehxA (14 isolates). The majority 85% of bovine STEC
isolates belonged to serotypes previously found among human STEC
strains and 54% to serotypes associated with STEC strains
isolated from patients with hemolytic uremic
syndrome.
Typing of eae (intimin) genes.
Forty-one strains of
serotypes O26:H11, O26:H-, O118:H16, O118:H-, O126:H-, OX177:H11,
OX177:H-, and ONT:H- had intimin ß1, 82 strains of serotype
O157:H7 possessed intimin
1, three strains of serotype O111:H-
had intimin type
2, one strain of serotype O49:H- showed
intimin type
, 13 strains of serotypes O103:H2, O103:H-,
O103:H21, O136:H-, O163:H21, O165:H21 and O165:H25 had intimin type
and eight strains of serotypes O84:H2, O138:H48, O150:H-,
O156:H-, O156:H25 and ONT:H25 had intimin
. We have identified
a new variant of the eae intimin gene designated
(xi) in two isolates of serotype
O80:H-.
Sequence comparison and evolutionary analysis of E. coli intimin genes.
An approximately 682-bp fragment of the
3' variable region of the eae gene was amplified with
universal eae primers EAE-F and EAE-RB from the STEC-B49
O80:H- strain and sequenced. As the eae sequence of STEC-B49
strain (accession number
AJ582912)
represents a new variant of the intimin gene, it has been designated
eae-
(xi) in order to follow the Greek
alphabet.
We determined the genetic relationship of the
3' variable region of the eae-
gene
(accession number
AJ582912,
fragment size 600 bp, primer coordinates 1 to 600) and the remaining 16
eae variants:
1
(AF022236,
635 bp, 2002 to 2636, aligned score 60%),
2
(AJ579368,
635 bp, 2002 to 2636, 54%), ß1
(AF453441,
635 bp, 2002 to 2636, 64%), ß2
(AF043226,
629 bp, 2005 to 2633, 63%),
1
(AF071034,
620 bp, 2002 to 2621, 58%),
2
(AF025311,
623 bp, 2002 to 2624, 59%),
(U66102, 638
bp, 2002 to 2639, 61%),
(AF116899,
644 bp, 2002 to 2645, 93%),
(AF449417,
629 bp, 2002 to 2630, 58%),
(AJ308550,
644 bp, 1992 to 2635, 91%),
(AF449418,
623 bp, 2002 to 2624, 59%),
(AJ308551,
632 bp, 2002 to 2633, 63%),
(AJ308552,
635 bp, 1992 to 2636, 62%),
(AF530557,
632 bp, 2002 to 2633, 56%), µ
(AJ579305,
622 bp, 1 to 622, 59%), and
(AJ579306,
635 bp, 16 to 650, 60%). Since the nucleotide sequences analyzed
were of different lengths (600 to 644 bp), we used CLUSTAL W for
optimal sequence alignment. Thus, the eae-
sequence
is similar to eae-
(identity of 93%) and
eae-
(identity of 91%) sequences. The
phylogenetic tree (Fig.
1) supports the data of the sequence identity values. Phylogenetic
analyses revealed five groups of the closely related intimin genes: (i)
1,
2,
and
; (ii) ß1,
ß2,
and
; (iii)
1,
2,
and µ; (iv)
and
; and (v)
,
and
.

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|
FIG. 1. Phylogenetic
tree of the intimin variant genes constructed with the CLUSTAL W
program. Numbers on the branches denote the genetic distance.
Phylogenetic analyses revealed five groups of the closely related
intimin genes: (i) 1, 2, , and ;
(ii) ß1, ß2, , and ; (iii)
1, 2, , and µ; (iv) and
; and (v) , , and
.
|
|
 |
DISCUSSION
|
|---|
The
results of our previous studies indicate that STEC colonization is
widespread among cattle in Spain. Between 1993 and 1995, 1,069 healthy
cattle were examined for STEC colonization. STEC-positive animals were
found in 95% of the farms examined and the estimated proportion
of positive cattle in each farm ranged from 0 to 100%. The
overall prevalence rates of STEC colonization were estimated to be
37% in calves and 27% in cows. In Spain,
stx2 and stx1
stx2 isolates were present in similar proportions
in calves and cows. In contrast, stx1 and
eae isolates were more commonly recovered from calves than
from cows. STEC O157:H7 was detected in only 8 (0.7%) of the
1,069 animals investigated. Interestingly, the majority of eae
non-O157 STEC and the eight STEC O157:H7 were isolated from calves,
confirming that young animals are the most important reservoir of
highly pathogenic eae STEC
(5,
8,
9).
In a survey
realized between 1998 and 1999, STEC O157:H7 was isolated from 55
(12%) of 471 feedlot calves (4 to 8 months of age). Although
only a mean of three animals per herd were sampled, STEC O157:H7
isolates were detected in 32 (22%) of 145 feedlots examined.
When we sampled a higher number of animals (9 to 56), STEC O157:H7 was
found in 3 (60%) of five feedlots investigated. Individual
prevalences in the three positive feedlots were 23% (13 of 56),
22% (two of nine) and 8% (1 of 13). Farms were visited
only in one occasion to collect fecal samples
(5). While the total
numbers of healthy and diarrheic calves positive for STEC did not vary
significantly, a significantly higher percentage of Stx1-producing
E. coli was found in diarrheic calves, suggesting a pathogenic
role in neonatal calf diarrhea
(5,
7). Similar prevalences of
STEC were found in other countries
(3,
15,
21,
22,
25,
33,
39,
41,
43,
44).
In the present
work, we have established the serotypes, virulence genes, and intimin
types of STEC isolated from cattle in previous studies
(5,
7,
8,
9) to know if bovine STEC
possess the same serotypes and virulence factor profiles that STEC
strains that cause human infection. STEC isolates belonged to 66 O
serogroups and 113 O:H serotypes (including 23 new serotypes). However,
67% were of one of these 15 serogroups (O2, O4, O8, O20, O22,
O26, O77, O91, O105, O113, O116, O157, O171, O174, and OX177) and
52% of isolates belonged to only 10 serotypes (O4:H4, O20:H19,
O22:H8, O26:H11, O77:H41, O105:H18, O113:H21, O157:H7, O171:H2, and
ONT:H19), including 10 serotypes also found among STEC strains that
cause human infections and six serotypes associated with hemolytic
uremic syndrome (O20:H19, O22:H8, O26:H11, O105:H18, O113:H21, and
O157:H7). Similarly, among the 20 serotypes most frequently isolated in
cattle or cattle products in Canada by Johnson et al.
(17), 18 have been
isolated from humans, and 11 of these are serotypes associated with
bloody diarrhea/hemorrhagic colitis and/or hemolytic uremic syndrome.
Pradel et al. (33) in
France, Beutin et al. (3),
and Montenegro et al.
(25) in Germany, Wells et
al. (39) in the United
States, and Parma et al.
(28) in Argentina have
also found that many STEC isolates recovered from cattle belong to
serotypes previously associated with human disease. Like other authors
(12,
17,
24,
40), we have observed
that bovine and human STEC isolates of the same serotype have similar
known virulence-associated properties.
The eae gene,
which has been shown to be necessary for attaching and effacing
activity, encodes a 94- to 97-kDa outer membrane protein which is
termed intimin (16,
20). Numerous
investigators have underlined the strong association between the
carriage of the eae gene and the capacity of STEC strains to
cause severe human disease, especially hemolytic uremic syndrome
(1,
27,
29). This important
virulence gene was detected in 100% of STEC O157:H7 and in
17% of non-O157 bovine isolates assayed in the present study.
Nevertheless, production of intimin is not essential for pathogenesis,
because a number of sporadic cases of hemolytic uremic syndrome have
been caused by eae-negative non-O157 STEC strains. Thus, STEC
O104:H21 and O113:H21 strains lacking the eae gene were
responsible for an outbreak and a cluster of three hemolytic uremic
syndrome cases in the United States and Australia, respectively
(30,
31). Furthermore,
recently Paton and Paton
(31) described a novel
megaplasmid-encoded adhesin (Saa) which we have detected in some of
bovine STEC strains lacking the eae gene (data not published).
This adhesin may be an important virulence factor of
eae-negative STEC strains capable of causing severe diseases
in humans.
Analysis of the nucleotide sequences of the intimin
genes from different STEC and enteropathogenic E. coli strains
has shown a high degree of homology in the 5' two-thirds of the
genes and a significant degree of heterogeneity in the 3'
one-third of the genes (1,
13). Fourteen variants of
the eae gene were identified by intimin type-specific PCR
assays with oligonucleotide primers complementary to the 3'end
of the specific intimin genes that encode the intimin types
1,
2, ß1, ß2,
1,
2/
,
/
,
,
,
,
,
, µ, and
(1, 6, 10, 18, 26, 27, 36, 37, 42;
Blanco et al., submitted).
In the present study, we have
identified a new intimin variant, designated intimin type
(xi) to follow the Greek alphabet. The eae-
(xi)
sequence of our bovine STEC-B49 O80:H- strain is almost identical
(>99%) to the eae genes sequenced by
K. G. Zehmke (accession numbers
AJ276416,
AJ275092,
AJ275103,
and
AJ275107,
unpublished data) from four STEC strains isolated from
calves in Germany and Belgium. As the eae-
sequence
is similar to the eae-
variant, K. G.
Zehmke assumed that his bovine STEC strains were positive for intimin
type
. Our phylogenetic analysis revealed that the
eae-
gene is closely related to intimin genes
eae-
and eae-
. As in human strains,
the intimin types ß1 and
1 are the most frequently
found among bovine STEC isolates. The intimin ß1 was mainly
found among strains belonging to serotype O26:H11, whereas the intimin
type
1 was detected in all 82 STEC O157:H7
assayed.
Seropathotypes O26:H11 stx1
eae-ß1, O157:H7 stx1
stx2 eae-
1 and O157:H7
stx1 stx2
eae-
1 are the most frequently observed in STEC
strains that cause human infections in Spain
(6). These highly virulent
seropathotypes were detected in 102 bovine STEC strains characterized
in the present study. Although our and other authors' results
indicate that STEC strains of human and animal origin with the same
serotype are similar in relation to the presence of known
virulence-associated factors
(4,
11,
12,
24,
34), the results of
Boerlin et al. (11)
suggest that STEC isolates from humans form a different population from
those found in the bovine reservoir or that they are only a
subpopulation of the latter. Thus, future studies are necessary to
establish if animal and human strains represent the same clones or are
only related subpopulations.
 |
ACKNOWLEDGMENTS
|
|---|
We
thank Monserrat Lamela for skillful technical
assistance.
This work was supported by grants from the
Fondo de Investigación Sanitaria (grants FIS G03-025-COLIRED-O157
and FIS 98/1158), the Xunta de Galicia (grant PGIDIT02BTF26101PR), the
Comisión Interministerial de Ciencia y Tecnología (grants
CICYT-ALI98-0616 and CICYT-FEDER-1FD1997-2181-C02-01), and the European
Commission (FAIR program grants CT98-4093 and CT98-3935). A. Mora and
G. Dahbi acknowledge the Xunta de Galicia and the Agencia
Española de Cooperación Internacional (AECI) for research
fellowships.
 |
FOOTNOTES
|
|---|
* Corresponding
author. Mailing address: Laboratorio de Referencia de E. coli,
Departamento de Microbioloxía e Parasitoloxía,
Facultade de Veterinaria, Universidade de Santiago de Compostela, 27002
Lugo, Spain. Phone and fax: 34-982-285936. E-mail:
jba{at}lugo.usc.es. 
 |
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Journal of Clinical Microbiology, February 2004, p. 645-651, Vol. 42, No. 2
0095-1137/04/$08.00+0 DOI: 10.1128/JCM.42.2.645-651.2004
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