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Erschienen in: Medical Microbiology and Immunology 3/2009

01.08.2009 | Review

What determines the success or failure of intracellular cutaneous parasites? Lessons learned from leishmaniasis

verfasst von: Marcus Maurer, Blaise Dondji, Esther von Stebut

Erschienen in: Medical Microbiology and Immunology | Ausgabe 3/2009

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Abstract

Most parasitic skin infections are averted by very efficient strategies of preventing pathogen invasion. Innate immune cells such as mast cells, macrophages and dendritic cells are responsible for detecting parasites and for recruiting proinflammatory cells that help to contain and control the pathogen at sites of infection. This induces efficient adaptive immunity, which is crucially important for parasite control. Using the example of cutaneous leishmaniasis, we highlight how the skin utilizes different strategies to prevent skin infection and how containment of the infection to the skin site may reduce the harm that otherwise may result for the entire organism.
Literatur
2.
Zurück zum Zitat Launois P, Tacchini-Cottier F, Parra-Lopez C, Louis JA (1998) Cytokines in parasitic diseases: the example of cutaneous leishmaniasis. Int Rev Immunol 17:157PubMed Launois P, Tacchini-Cottier F, Parra-Lopez C, Louis JA (1998) Cytokines in parasitic diseases: the example of cutaneous leishmaniasis. Int Rev Immunol 17:157PubMed
4.
Zurück zum Zitat Etges R, Muller I (1998) Progressive disease or protective immunity to Leishmania major infection: the result of a network of stimulatory and inhibitory interactions. J Mol Med 76:372. doi:10.1007/s001090050230 PubMedCrossRef Etges R, Muller I (1998) Progressive disease or protective immunity to Leishmania major infection: the result of a network of stimulatory and inhibitory interactions. J Mol Med 76:372. doi:10.​1007/​s001090050230 PubMedCrossRef
5.
Zurück zum Zitat Dondji B, Duhlinska DD, Same-Ekobo A, Yimagou I (1998) Clinical and parasitological prevalence of cutaneous leishmaniasis in Mokolo focus, Far North Province of Cameroon. Bull Liais Doc OCEAC 31:40 Dondji B, Duhlinska DD, Same-Ekobo A, Yimagou I (1998) Clinical and parasitological prevalence of cutaneous leishmaniasis in Mokolo focus, Far North Province of Cameroon. Bull Liais Doc OCEAC 31:40
6.
Zurück zum Zitat Couppie P, Clyti E, Sainte-Marie D, Dedet JP, Carme B, Pradinaud R (2004) Disseminated cutaneous leishmaniasis due to Leishmania guyanensis: case of a patient with 425 lesions. Am J Trop Med Hyg 71:558PubMed Couppie P, Clyti E, Sainte-Marie D, Dedet JP, Carme B, Pradinaud R (2004) Disseminated cutaneous leishmaniasis due to Leishmania guyanensis: case of a patient with 425 lesions. Am J Trop Med Hyg 71:558PubMed
11.
Zurück zum Zitat Kane MM, Mosser DM (2001) The role of IL-10 in promoting disease progression in leishmaniasis. J Immunol 166:1141PubMed Kane MM, Mosser DM (2001) The role of IL-10 in promoting disease progression in leishmaniasis. J Immunol 166:1141PubMed
13.
Zurück zum Zitat Lai Y, Gallo RL (2008) Toll-like receptors in skin infections and inflammatory diseases. Infect Disord Drug Targets 8:144PubMed Lai Y, Gallo RL (2008) Toll-like receptors in skin infections and inflammatory diseases. Infect Disord Drug Targets 8:144PubMed
14.
Zurück zum Zitat Curry JL, Qin JZ, Bonish B, Carrick R, Bacon P, Panella J, Robinson J, Nickoloff BJ (2003) Innate immune-related receptors in normal and psoriatic skin. Arch Pathol Lab Med 127:178PubMed Curry JL, Qin JZ, Bonish B, Carrick R, Bacon P, Panella J, Robinson J, Nickoloff BJ (2003) Innate immune-related receptors in normal and psoriatic skin. Arch Pathol Lab Med 127:178PubMed
16.
Zurück zum Zitat Thoma-Uszynski S, Stenger S, Takeuchi O, Ochoa MT, Engele M, Sieling PA, Barnes PF, Rollinghoff M, Bolcskei PL, Wagner M, Akira S, Norgard MV, Belisle JT, Godowski PJ, Bloom BR, Modlin RL (2001) Induction of direct antimicrobial activity through mammalian toll-like receptors. Science 291:1544. doi:10.1126/science.291.5508.1544 PubMedCrossRef Thoma-Uszynski S, Stenger S, Takeuchi O, Ochoa MT, Engele M, Sieling PA, Barnes PF, Rollinghoff M, Bolcskei PL, Wagner M, Akira S, Norgard MV, Belisle JT, Godowski PJ, Bloom BR, Modlin RL (2001) Induction of direct antimicrobial activity through mammalian toll-like receptors. Science 291:1544. doi:10.​1126/​science.​291.​5508.​1544 PubMedCrossRef
17.
Zurück zum Zitat Muraille E, De Trez C, Brait M, De Baetselier P, Leo O, Carlier Y (2003) Genetically resistant mice lacking MyD88-adapter protein display a high susceptibility to Leishmania major infection associated with a polarized Th2 response. J Immunol 170:4237PubMed Muraille E, De Trez C, Brait M, De Baetselier P, Leo O, Carlier Y (2003) Genetically resistant mice lacking MyD88-adapter protein display a high susceptibility to Leishmania major infection associated with a polarized Th2 response. J Immunol 170:4237PubMed
18.
Zurück zum Zitat Lopez Kostka S, Knop J, Konur A, Udey MC, von Stebut E (2006) Distinct roles for IL-1 receptor type I signaling in early versus established Leishmania major infections. J Invest Dermatol 126:1582. doi:10.1038/sj.jid.5700309 CrossRef Lopez Kostka S, Knop J, Konur A, Udey MC, von Stebut E (2006) Distinct roles for IL-1 receptor type I signaling in early versus established Leishmania major infections. J Invest Dermatol 126:1582. doi:10.​1038/​sj.​jid.​5700309 CrossRef
20.
Zurück zum Zitat Asghar SS, Pasch MC (1998) Complement as a promiscuous signal transduction device. Lab Invest 78:1203PubMed Asghar SS, Pasch MC (1998) Complement as a promiscuous signal transduction device. Lab Invest 78:1203PubMed
24.
Zurück zum Zitat Fayyazi A, Sandau R, Duong LQ, Götze O, Radzun HJ, Schweyer S, Soruri A, Zwirner J (1999) C5a receptor and interleukin-6 are expressed in tissue macrophages and stimulated keratinocytes but not in pulmonary and intestinal epithelial cells. Am J Pathol 154:495PubMed Fayyazi A, Sandau R, Duong LQ, Götze O, Radzun HJ, Schweyer S, Soruri A, Zwirner J (1999) C5a receptor and interleukin-6 are expressed in tissue macrophages and stimulated keratinocytes but not in pulmonary and intestinal epithelial cells. Am J Pathol 154:495PubMed
25.
Zurück zum Zitat Füreder W, Agis H, Willheim M, Bankl HC, Maier U, Kishi K, Müller MR, Czerwenka K, Radaszkiewicz T, Butterfield JH, Klappacher GW, Sperr WR, Oppermann M, Lechner K, Valent P (1995) Differential expression of complement receptors on human basophils and mast cells. Evidence for mast cell heterogeneity and CD88/C5aR expression on skin mast cells. J Immunol 155:3152PubMed Füreder W, Agis H, Willheim M, Bankl HC, Maier U, Kishi K, Müller MR, Czerwenka K, Radaszkiewicz T, Butterfield JH, Klappacher GW, Sperr WR, Oppermann M, Lechner K, Valent P (1995) Differential expression of complement receptors on human basophils and mast cells. Evidence for mast cell heterogeneity and CD88/C5aR expression on skin mast cells. J Immunol 155:3152PubMed
26.
Zurück zum Zitat Wojta J, Kaun C, Zorn G, Ghannadan M, Hauswirth AW, Sperr WR, Fritsch G, Printz D, Binder BR, Schatzl G, Zwirner J, Maurer G, Huber K, Valent P (2002) C5a stimulates production of plasminogen activator inhibitor-1 in human mast cells and basophils. Blood 100:517. doi:10.1182/blood.V100.2.517 PubMedCrossRef Wojta J, Kaun C, Zorn G, Ghannadan M, Hauswirth AW, Sperr WR, Fritsch G, Printz D, Binder BR, Schatzl G, Zwirner J, Maurer G, Huber K, Valent P (2002) C5a stimulates production of plasminogen activator inhibitor-1 in human mast cells and basophils. Blood 100:517. doi:10.​1182/​blood.​V100.​2.​517 PubMedCrossRef
27.
Zurück zum Zitat Werfel T, Kirchhoff K, Wittmann M, Begemann G, Kapp A, Heidenreich F, Götze O, Zwirner J (2000) Activated human T lymphocytes express a functional C3a receptor. J Immunol 165:6599PubMed Werfel T, Kirchhoff K, Wittmann M, Begemann G, Kapp A, Heidenreich F, Götze O, Zwirner J (2000) Activated human T lymphocytes express a functional C3a receptor. J Immunol 165:6599PubMed
31.
Zurück zum Zitat Reis e Sousa C, Diebold SD, Edwards AD, Rogers N, Schulz O, Spörri R (2003) Regulation of dendritic cell function by microbial stimuli. Pathol Biol (Paris) 51:67. doi:10.1016/S0369-8114(03)00099-3 Reis e Sousa C, Diebold SD, Edwards AD, Rogers N, Schulz O, Spörri R (2003) Regulation of dendritic cell function by microbial stimuli. Pathol Biol (Paris) 51:67. doi:10.​1016/​S0369-8114(03)00099-3
32.
Zurück zum Zitat Ritter U, Meissner A, Scheidig C, Körner H (2004) CD8 alpha- and Langerin-negative dendritic cells, but not Langerhans cells, act as principal antigen-presenting cells in leishmaniasis. Eur J Immunol 34:1542. doi:10.1002/eji.200324586 PubMedCrossRef Ritter U, Meissner A, Scheidig C, Körner H (2004) CD8 alpha- and Langerin-negative dendritic cells, but not Langerhans cells, act as principal antigen-presenting cells in leishmaniasis. Eur J Immunol 34:1542. doi:10.​1002/​eji.​200324586 PubMedCrossRef
33.
Zurück zum Zitat Wu L, Dakic A (2004) Development of dendritic cell system. Cell Mol Immunol 1:112PubMed Wu L, Dakic A (2004) Development of dendritic cell system. Cell Mol Immunol 1:112PubMed
36.
Zurück zum Zitat Belkaid Y, Mendez S, Lira R, Kadambi N, Milon G, Sacks D (2000) A natural model of Leishmania major infection reveals a prolonged “silent” phase of parasite amplification in the skin before the onset of lesion formation and immunity. J Immunol 165:969PubMed Belkaid Y, Mendez S, Lira R, Kadambi N, Milon G, Sacks D (2000) A natural model of Leishmania major infection reveals a prolonged “silent” phase of parasite amplification in the skin before the onset of lesion formation and immunity. J Immunol 165:969PubMed
37.
Zurück zum Zitat von Stebut E, Metz M, Milon G, Knop J, Maurer M (2003) Early macrophage influx to sites of cutaneous granuloma formation is dependent on MIP-1α/β released from neutrophils recruited by mast cell-derived TNFα. Blood 101:210. doi:10.1182/blood-2002-03-0921 CrossRef von Stebut E, Metz M, Milon G, Knop J, Maurer M (2003) Early macrophage influx to sites of cutaneous granuloma formation is dependent on MIP-1α/β released from neutrophils recruited by mast cell-derived TNFα. Blood 101:210. doi:10.​1182/​blood-2002-03-0921 CrossRef
38.
41.
Zurück zum Zitat von Stebut E (2007) Immunology of cutaneous leishmaniasis: the role of mast cells, phagocytes and dendritic cells for protective immunity. Eur J Dermatol 17:115 von Stebut E (2007) Immunology of cutaneous leishmaniasis: the role of mast cells, phagocytes and dendritic cells for protective immunity. Eur J Dermatol 17:115
42.
Zurück zum Zitat Hornell TM, Beresford GW, Bushey A, Boss JM, Mellins ED (2003) Regulation of the class II MHC pathway in primary human monocytes by granulocyte-macrophage colony-stimulating factor. J Immunol 171:2374PubMed Hornell TM, Beresford GW, Bushey A, Boss JM, Mellins ED (2003) Regulation of the class II MHC pathway in primary human monocytes by granulocyte-macrophage colony-stimulating factor. J Immunol 171:2374PubMed
43.
Zurück zum Zitat Woelbing F, Kostka SL, Moelle K, Belkaid Y, Sunderkoetter C, Verbeek S, Waisman A, Nigg AP, Knop J, Udey MC, von Stebut E (2006) Uptake of Leishmania major by dendritic cells is mediated by Fcgamma receptors and facilitates acquisition of protective immunity. J Exp Med 203:177. doi:10.1084/jem.20052288 PubMedCrossRef Woelbing F, Kostka SL, Moelle K, Belkaid Y, Sunderkoetter C, Verbeek S, Waisman A, Nigg AP, Knop J, Udey MC, von Stebut E (2006) Uptake of Leishmania major by dendritic cells is mediated by Fcgamma receptors and facilitates acquisition of protective immunity. J Exp Med 203:177. doi:10.​1084/​jem.​20052288 PubMedCrossRef
44.
Zurück zum Zitat Campbell JJ, Haraldsen G, Pan J, Rottman J, Qin S, Ponath P, Andrew DP, Warnke R, Ruffing N, Kassam N, Wu L, Butcher EC (1999) The chemokine receptor CCR4 in vascular recognition by cutaneous but not intestinal memory T cells. Nature 400:776. doi:10.1038/23495 PubMedCrossRef Campbell JJ, Haraldsen G, Pan J, Rottman J, Qin S, Ponath P, Andrew DP, Warnke R, Ruffing N, Kassam N, Wu L, Butcher EC (1999) The chemokine receptor CCR4 in vascular recognition by cutaneous but not intestinal memory T cells. Nature 400:776. doi:10.​1038/​23495 PubMedCrossRef
48.
Zurück zum Zitat Koelle DM, Liu Z, McClurkan CM, Topp MS, Riddell SR, Pamer EG, Johnson AS, Wald A, Corey L (2002) Expression of cutaneous lymphocyte-associated antigen by CD8+ T cells specific for a skin-tropic virus. J Clin Invest 110:537PubMed Koelle DM, Liu Z, McClurkan CM, Topp MS, Riddell SR, Pamer EG, Johnson AS, Wald A, Corey L (2002) Expression of cutaneous lymphocyte-associated antigen by CD8+ T cells specific for a skin-tropic virus. J Clin Invest 110:537PubMed
51.
Zurück zum Zitat Morales J, Homey B, Vicari AP, Hudak S, Oldham E, Hedrick J, Orozco R, Copeland NG, Jenkins NA, McEvoy LM, Zlotnik A (1999) CTACK, a skin-associated chemokine that preferentially attracts skin-homing memory T cells. Proc Natl Acad Sci USA 96:14470. doi:10.1073/pnas.96.25.14470 PubMedCrossRef Morales J, Homey B, Vicari AP, Hudak S, Oldham E, Hedrick J, Orozco R, Copeland NG, Jenkins NA, McEvoy LM, Zlotnik A (1999) CTACK, a skin-associated chemokine that preferentially attracts skin-homing memory T cells. Proc Natl Acad Sci USA 96:14470. doi:10.​1073/​pnas.​96.​25.​14470 PubMedCrossRef
52.
Zurück zum Zitat Engeman T, Gorbachev AV, Kish DD, Fairchild RL (2004) The intensity of neutrophil infiltration controls the number of antigen-primed CD8 T cells recruited into cutaneous antigen challenge sites. J Leukoc Biol 76:941. doi:10.1189/jlb.0304193 PubMedCrossRef Engeman T, Gorbachev AV, Kish DD, Fairchild RL (2004) The intensity of neutrophil infiltration controls the number of antigen-primed CD8 T cells recruited into cutaneous antigen challenge sites. J Leukoc Biol 76:941. doi:10.​1189/​jlb.​0304193 PubMedCrossRef
53.
Zurück zum Zitat Reis e Sousa C, Hieny S, Scharton-Kersten T, Jankovic D, Charest H, Germain RN, Sher A (1997) In vivo microbial stimulation induces rapid CD40 ligand-independent production of interleukin 12 by dendritic cells and their redistribution to T cell areas. J Exp Med 186:1819. doi:10.1084/jem.186.11.1819 PubMedCrossRef Reis e Sousa C, Hieny S, Scharton-Kersten T, Jankovic D, Charest H, Germain RN, Sher A (1997) In vivo microbial stimulation induces rapid CD40 ligand-independent production of interleukin 12 by dendritic cells and their redistribution to T cell areas. J Exp Med 186:1819. doi:10.​1084/​jem.​186.​11.​1819 PubMedCrossRef
54.
Zurück zum Zitat von Stebut E, Belkaid Y, Jakob T, Sacks DL, Udey MC (1998) Uptake of Leishmania major amastigotes results in activation and interleukin 12 release from murine skin-derived dendritic cells: implications for the initiation of anti-Leishmania immunity. J Exp Med 188:1547. doi:10.1084/jem.188.8.1547 CrossRef von Stebut E, Belkaid Y, Jakob T, Sacks DL, Udey MC (1998) Uptake of Leishmania major amastigotes results in activation and interleukin 12 release from murine skin-derived dendritic cells: implications for the initiation of anti-Leishmania immunity. J Exp Med 188:1547. doi:10.​1084/​jem.​188.​8.​1547 CrossRef
59.
Zurück zum Zitat Lopez Kostka S, Dinges S, Iwakura Y, Udey MC, von Stebut E (2009) IL-17 contributes to disease susceptibility in cutaneous leishmaniasis. J Immunol 182: (in press). doi:10.4049/jimmunol.0713598 Lopez Kostka S, Dinges S, Iwakura Y, Udey MC, von Stebut E (2009) IL-17 contributes to disease susceptibility in cutaneous leishmaniasis. J Immunol 182: (in press). doi:10.​4049/​jimmunol.​0713598
60.
Zurück zum Zitat Tacchini-Cottier F, Zweifel C, Belkaid Y, Mukankundiye C, Vasei M, Launois P, Milon G, Louis JA (2000) An immunomodulatory function for neutrophils during the induction of a CD4+ Th2 response in BALB/c mice infected with Leishmania major. J Immunol 165:2628PubMed Tacchini-Cottier F, Zweifel C, Belkaid Y, Mukankundiye C, Vasei M, Launois P, Milon G, Louis JA (2000) An immunomodulatory function for neutrophils during the induction of a CD4+ Th2 response in BALB/c mice infected with Leishmania major. J Immunol 165:2628PubMed
61.
Zurück zum Zitat Ribeiro-Gomes FL, Otero AC, Gomes NA, Moniz-De-Souza MC, Cysne-Finkelstein L, Arnholdt AC, Calich VL, Coutinho SG, Lopes MF, DosReis GA (2004) Macrophage interactions with neutrophils regulate Leishmania major infection. J Immunol 172:4454PubMed Ribeiro-Gomes FL, Otero AC, Gomes NA, Moniz-De-Souza MC, Cysne-Finkelstein L, Arnholdt AC, Calich VL, Coutinho SG, Lopes MF, DosReis GA (2004) Macrophage interactions with neutrophils regulate Leishmania major infection. J Immunol 172:4454PubMed
65.
Zurück zum Zitat Belkaid Y, Hoffmann KF, Mendez S, Kamhawi S, Udey MC, Wynn TA, Sacks DL (2001) The role of interleukin (IL)-10 in the persistence of Leishmania major in the skin after healing and the therapeutic potential of anti-IL-10 receptor antibody for sterile cure. J Exp Med 194:1497. doi:10.1084/jem.194.10.1497 PubMedCrossRef Belkaid Y, Hoffmann KF, Mendez S, Kamhawi S, Udey MC, Wynn TA, Sacks DL (2001) The role of interleukin (IL)-10 in the persistence of Leishmania major in the skin after healing and the therapeutic potential of anti-IL-10 receptor antibody for sterile cure. J Exp Med 194:1497. doi:10.​1084/​jem.​194.​10.​1497 PubMedCrossRef
66.
Zurück zum Zitat von Stebut E, Ehrchen JM, Belkaid Y, Lopez Kostka S, Mölle K, Knop J, Sunderkötter C, Udey MC (2003) IL-1α promotes Th1-differentiation and inhibits disease progression in Leishmania major-susceptible BALB/c mice. J Exp Med 198:191. doi:10.1084/jem.20030159 CrossRef von Stebut E, Ehrchen JM, Belkaid Y, Lopez Kostka S, Mölle K, Knop J, Sunderkötter C, Udey MC (2003) IL-1α promotes Th1-differentiation and inhibits disease progression in Leishmania major-susceptible BALB/c mice. J Exp Med 198:191. doi:10.​1084/​jem.​20030159 CrossRef
67.
Zurück zum Zitat Nigg AP, Zahn S, Rückerl D, Hölscher C, Yoshimoto T, Ehrchen JM, Wölbing F, Udey MC, von Stebut E (2007) Dendritic cell-derived IL-12p40 homodimer contributes to susceptibility in cutaneous leishmaniasis in BALB/c mice. J Immunol 178:7251PubMed Nigg AP, Zahn S, Rückerl D, Hölscher C, Yoshimoto T, Ehrchen JM, Wölbing F, Udey MC, von Stebut E (2007) Dendritic cell-derived IL-12p40 homodimer contributes to susceptibility in cutaneous leishmaniasis in BALB/c mice. J Immunol 178:7251PubMed
69.
Zurück zum Zitat Carrera L, Gazzinelli RT, Badolato R, Hieny S, Muller W, Kuhn R, Sacks DL (1996) Leishmania promastigotes selectively inhibit interleukin 12 induction in bone marrow-derived macrophages from susceptible and resistant mice. J Exp Med 183:515. doi:10.1084/jem.183.2.515 PubMedCrossRef Carrera L, Gazzinelli RT, Badolato R, Hieny S, Muller W, Kuhn R, Sacks DL (1996) Leishmania promastigotes selectively inhibit interleukin 12 induction in bone marrow-derived macrophages from susceptible and resistant mice. J Exp Med 183:515. doi:10.​1084/​jem.​183.​2.​515 PubMedCrossRef
75.
Zurück zum Zitat Launois P, Maillard I, Pingel S, Swihart KG, Xénarios I, Acha-Orbea H, Diggelmann H, Locksley RM, MacDonald HR, Louis JA (1997) IL-4 rapidly produced by V beta 4 V alpha 8 CD4+ T cells instructs Th2 development and susceptibility to Leishmania major in BALB/c mice. Immunity 6:541. doi:10.1016/S1074-7613(00)80342-8 PubMedCrossRef Launois P, Maillard I, Pingel S, Swihart KG, Xénarios I, Acha-Orbea H, Diggelmann H, Locksley RM, MacDonald HR, Louis JA (1997) IL-4 rapidly produced by V beta 4 V alpha 8 CD4+ T cells instructs Th2 development and susceptibility to Leishmania major in BALB/c mice. Immunity 6:541. doi:10.​1016/​S1074-7613(00)80342-8 PubMedCrossRef
77.
Zurück zum Zitat Malherbe L, Filippi C, Julia V, Foucras G, Moro M, Appel H, Wucherpfennig K, Guéry JC, Glaichenhaus N (2000) Selective activation and expansion of high-affinity CD4+ T cells in resistant mice upon infection with Leishmania major. Immunity 13:771. doi:10.1016/S1074-7613(00)00075-3 PubMedCrossRef Malherbe L, Filippi C, Julia V, Foucras G, Moro M, Appel H, Wucherpfennig K, Guéry JC, Glaichenhaus N (2000) Selective activation and expansion of high-affinity CD4+ T cells in resistant mice upon infection with Leishmania major. Immunity 13:771. doi:10.​1016/​S1074-7613(00)00075-3 PubMedCrossRef
Metadaten
Titel
What determines the success or failure of intracellular cutaneous parasites? Lessons learned from leishmaniasis
verfasst von
Marcus Maurer
Blaise Dondji
Esther von Stebut
Publikationsdatum
01.08.2009
Verlag
Springer-Verlag
Erschienen in
Medical Microbiology and Immunology / Ausgabe 3/2009
Print ISSN: 0300-8584
Elektronische ISSN: 1432-1831
DOI
https://doi.org/10.1007/s00430-009-0114-9

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