Loading

Archives of Emergency Medicine and Critical Care

Curvularia and the Brain: Case Demonstration of Optimal Management

Case Report | Open Access Volume 6 | Issue 1 |

  • 1. Department of Neurosurgery, University of Florida, USA
  • 2. Department of Pathology, Immunology and Laboratory Medicine, University of Florida, USA
  • 3. Department of Otolaryngology, University of Florida, USA
+ Show More - Show Less
Corresponding Authors
Brandon Lucke-Wold, Department of Neurosurgery,University of Florida, Gainesville, FL, USA, email: Brandon.Lucke-Wold@neurosurgery.ufl.edu
Abstract

Background: Curvularia is a ubiquitous fungus found in tropical climates and has been reported to grow on marijuana leaves. Rarely, it can infect humans and propagate from the nasal sinuses into the brain.

Case: A 28-year-old immunocompetent patient presented with history of nasal polyps, headache, and subtle visual deficits on the right. Imaging revealed what appeared to be an invasive mass growing through the ethmoid and sphenoid sinuses into the anterior cranial fossa.

Results: Otolaryngology performed an endoscopic nasal biopsy with pathology and cultures consistent for Curvularia (figure 6). A combination case with neurosurgery and otolaryngology was planned. Surgeons used a bifrontal craniotomy and endonasal approach for gross total resection. Following resection, the patient was placed on 4 weeks of amphotericin treatment followed by 12 months of voriconazole based on recommendations by infectious disease. The patient has been stable since surgery.

Conclusion: Curvularia is a rare but potentially life threatening central nervous system infection that can be acquired from inhalational marijuana use. This illustrative case shows the importance of aggressive debridement followed by broad spectrum antifungal treatment to optimize outcome. With marijuana’s increasing popularity, Curvalaria should be included on the differential diagnosis.

Keywords

• Fungus; Debridement; Anti-fungals; Multidisciplinary care; Nasal polyps

Citation

Goldman M, Reddy R, Lucke-Wold B, Barpujari A, Cameron M, et al. (2022) Curvularia and the Brain: Case Demonstration of Optimal Management. Arch Emerg Med Crit Care 6(1): 1051.

BACKGROUND

Curvularia is a filamentous, dematiaceous, ubiquitous fungus that causes rare, but often fatal CNS phaeohyphomycotic infections [1]. Phaeohyphomycotic infections generally have poor prognosis and are caused by dematiaceous fungi, identified by elevated levels of melanin in their cell walls [2]. Thus far, there have been only a few reports of patients with Curvularia infections, but the most common strain is C. lunata (others include C. pallescens, C. clavate, and C. geniculate) [3-9].

Curvularia infections can present acutely, but more commonly, present as gradual, chronic neurologic changes over several months [10]. Patients may present with chronic sinusitis, keratitis, cutaneous infection, onychomycosis, respiratory infection, endocarditis, and cerebral abscesses [1,10]. Abscesses in soft tissues (pulmonary, paravertebral, or cerebral abscesses) seem to be correlated especially with the C. lunata species [4,5,7,8]. Optic nerve atrophy may occur depending on the location of the cerebral abscess [1]. Although immunocompromised patients might be more prone to Curvularia, it is not necessary for development of the infection [10].

Pathological findings show infiltrates that can include lymphocytes and multi-nucleated giant cells, as well as fungal hyphae with terminal globose dilatation that are often characteristic of Curvularia (seen via Grocott’s Methenamine stain (GMS) [1]. If the patient presents with a long or chronic history, this often suggests that the mechanism of infection is via inhalation of spores, colonization of sinuses, followed by local invasion into the frontal lobe and/or skull base [11]. Although no singular treatment protocol has been determined for Curvularia infections, it is known that general phaeohyphomycotic infections respond poorly to typical antifungals (e.g.: fluconazole) but patients respond better to combinations of antifungals and complete surgical excision of the destructive mass [2]. The period of disease-free follow-up from intracranial Curvularia infection has been reported to be 3 years in 2013 [1]. The patient case mentioned above followed the use of antifungals and antibacterial pre-op, followed by surgical excision, and post-op antibiotics [1]. Serial MRIs are used for follow-up [1]. If significant erosion of facial bones and/or skull base is present, pericranial grafts may be used for reconstruction [1]. Below we present our unique case and use the features to highlight important teaching points.

CASE

A 28-year-old immunocompetent African American male presented to the emergency room following a motor vehicle collision where a Computed Tomography (CT) scan of the head was obtained. Which revealed an incidental large sinonasal lesion with intracranial extension was noted as seen in Figure 1.

CT scan with axial and coronal slices of the brain showing a  hyperdense mass in right anterior cranial fossa with extension into the right  ethmoid. The mass measured 5.2 x 3.8 x 3.8 cm (AP, transverse, craniocaudal).  There is surrounding vasogenic edema present (R>L), with minimal lesional  extension across midline into the left mesial frontal lobe. Approximately 3mm  right-to-left shift is present at the level of the third ventricle

Figure 1: CT scan with axial and coronal slices of the brain showing a hyperdense mass in right anterior cranial fossa with extension into the right ethmoid. The mass measured 5.2 x 3.8 x 3.8 cm (AP, transverse, craniocaudal). There is surrounding vasogenic edema present (R>L), with minimal lesional extension across midline into the left mesial frontal lobe. Approximately 3mm right-to-left shift is present at the level of the third ventricle

Upon further questioning, it was discovered that he had developed persistent headaches, photophobia, chronic rhinosinusitis, and right sided vision loss over the course of three months. Of note, he had endoscopic sinus surgery for polyp while incarcerated approximately 10 years aprior. Due to the presence of the lesion, and unknown origin, Otolaryngology was consulted for and performed Endoscopic Sinus Surgery (ESS) with biopsy. Upon opening the maxillary and ethmoid sinuses, the performing surgeon noted a rubbery, firm mass that appeared to have morphed the present sinus tissues and was extending through the cirbiform, and planum into the intracranial space. Tissue removal was stopped at the skull base and focused on the sphenoid and ethmoid sinuses. Surgical pathology and tissue cultures were sent, and the patient had an otherwise uncomplicated course.

Final pathology revealed chronic granulomatous invasive fungal sinusitis and chronic polypoidal sinusitis consistent with Curvularia species (Figure 6).

A) 20x H&E showing the Culvularia buds in association with giant cells. B) 40x view of the pigmented organisms with their characteristic bulbous morphology.  C) 20x GMS stain showing the Culvularia. D) 40x GMS stain showing classic grouping.

Figure 6: A) 20x H&E showing the Culvularia buds in association with giant cells. B) 40x view of the pigmented organisms with their characteristic bulbous morphology. C) 20x GMS stain showing the Culvularia. D) 40x GMS stain showing classic grouping.

The patient was started on Amphotericin B and voriconazole.

A combined endoscopic and open approach was then planned with otolaryngology and neurosurgery, with plan for endoscopic resection of the fungal mass down to the skull base and clearance of the sinuses, followed by open resection via a bifrontal craniotomy. Endoscopic resection was taken to the anterior cranial fossa dura, removing the bony skull base and exposing the dura adjacent the superomedial orbit, posterior to the planum, medially along the olfactory cleft, and anteriorly to the extent of the cribriform plate, exposing the area where the mass had penetrated the intracranial space with a wide dural margin. At this point bifrontal craniotomy was performed by the neurosurgical team. The dura was opened, and lesion was debulked. The anterior aspect of the sagittal sinus was ligated. The remainder of the lesion extending into the optic canal was then removed with Rhoton curretes. The lesion was then dissected from the frontal lobe with preservation of anterior cerebral artery branches (Figure 2).

The lesion is seen here through a bifrontal craniotomy exposure. The  fungal lesion is photographed being removed with aggressive debulking using a  fifteen blade. Tissue from this region was sent to pathology.

Figure 2: The lesion is seen here through a bifrontal craniotomy exposure. The fungal lesion is photographed being removed with aggressive debulking using a fifteen blade. Tissue from this region was sent to pathology.

Attention was then transitioned to the lesion abutting the olfactory tracks with complete resection (Figure 3).

Intraoperative fungal specimen photographed here prior to being  packaged and sent to pathology. Internal debulking was done in a piecewise  fashion and select specimens from frontal lobe lesion are photographed here.

Figure 3: Intraoperative fungal specimen photographed here prior to being packaged and sent to pathology. Internal debulking was done in a piecewise fashion and select specimens from frontal lobe lesion are photographed here.

Frontal lobe encephalomalacia was noted and abnormal brain tissue was resected. The defect was then closed with abdominal fat graft, pericranial flap, and lyoplant. Once this was complete, attention was repaid to the ethmoid roof and the skull base, and reconstruction was then performed using a posterior septal artery pedicle nasoseptal flap to ensure successful dural closure (Figure 4).

Adequate closure was simultaneously evaluated superiorly by  neurosurgery and inferiorly by otolaryngology.

Figure 4: Adequate closure was simultaneously evaluated superiorly by neurosurgery and inferiorly by otolaryngology.

Once this was performed, the bifrontal cranial incision was closed.

The procedure took approximately sixteen hours in total and was completed without complications. Immediately post operatively the patient was neurologically stable with preservation of pre-operative vision despite extensive optic nerve involvement. The post-operative magnetic resonance imaging (MRI) showed good resection of lesion (Figure 5).

Post operative T2 MRI sequence taken four days after bifrontal  craniotomy and endonasal resection of right frontal abscess. No evidence of  residual macroscopic disease with improving right frontal edema

Figure 5: Post operative T2 MRI sequence taken four days after bifrontal craniotomy and endonasal resection of right frontal abscess. No evidence of residual macroscopic disease with improving right frontal edema

Post operatively the infectious disease recommended 4 weeks of amphotericin treatment followed by 12 months of voriconazole. Patient was discharged with near term follow up for planned repeat MRI. At the patient’s most recent otolaryngology follow up, there was no sign of cerebrospinal fluid (CSF) leak, however the patient did complain of significant nasal crusting due to his persistent avoidance of saline lavage post operatively.

DISCUSSION

Epidemiology

Curvularia is a pigmented filamentous fungus found in tropical and subtropical regions [12]. Infection has been reported secondary to skin abrasions, catheter infections, and ocular trauma [13]. As in this case, nasal polyps have long been suggested as a predisposing risk factor [14]. Our patient additionally had chronic sinusitis, which is similar to prior reported cases by Ebright and Gadgil [1,15].

Potential infection sites include the heart [16], lungs [17,18], and urinary tract. Rarely, infection occurs in the central nervous system, and when it does it is often fatal [1]. There is a theorized association between marijuana smoking and Curvalaria infection [22]. Two prior case reports have detailed immunocompetent patients using marijuana who acquired CNS curvalaria infections [7,13]. Similarly, our patient reported occasional marijuana use, which may have been his exposure source. Due to the rarity of this infection, the influence of marijuana on fungal inoculation/ susceptibility is based off ancetodal evidence and needs further validation [13]. Skovrlj suggested a strong relationship may be present due to growth on marijuana leaves [12]. This important factor of the social history should therefore not to be overlooked (Figure 7).

This diagram highlights commonly accepted risk factors including marijuana smoking, living in a tropical/sub-tropical climate, and history of nasal polyps. All  three risk factors were present in this reported case.

Figure 7: This diagram highlights commonly accepted risk factors including marijuana smoking, living in a tropical/sub-tropical climate, and history of nasal polyps. All three risk factors were present in this reported case.

To our knowledge only nine cases have been reported involving the central nervous system since 1977 [12]. An updated infographic on previously reported CNS infections since 1977 including our most recent case is presented in Figure 8.

This infographic shows updated epidemiology, pharmacological management, and last reported outcomes of case reports since 1977. The study detailed in  this paper was incorporated into the data presented.  1: Clinical outcome was based off previously reported long-term follow up. Our case was excluded from this calculation as long- term follow up is not yet available.

Figure 8: This infographic shows updated epidemiology, pharmacological management, and last reported outcomes of case reports since 1977. The study detailed in this paper was incorporated into the data presented. 1: Clinical outcome was based off previously reported long-term follow up. Our case was excluded from this calculation as long- term follow up is not yet available.

In prior case reports, CNS infections have been most commonly in the frontal and parietal lobe [13]. Cases have also been documented in deeper brain structures including the basal ganglia [7], and sellar region [20]. Fungal infections of the CNS generally affect immunocompromised patients (e.g. cryptococcal meningitis in HIV patient), but most cases of CNS Curvalaria have been reported in immunocompetent hosts. Including our report, 7/10 case reports were in immunocompetent patients.

Management

To date there is no standardized treatment regimen for Curvularia infections and prior published cases were used to help guide clinical decision making. Since 1977 there have been only nine reported cases of CNS infections [12]. A case with striking resemblance to ours was reported by Gadgil in 2012. Similarly, they reported an immunocompetent patient with history of previous sinus surgery presenting with a symptomatic CNS infection from Curvalaria. Although other cases proved to be fatal even with surgical and pharmacological treatment [19], Gadgil documented freedom from recurrent disease three years following discharge when complete resection is achieved [1]. With aggressive surgical resection and dual antifungal therapy, mortality rates are reported to be as high as 73% [19]. Including our most recent case mortality rates have been reduced to 33% (Figure 8) [12].

Upon reviewing recent published cases, amphotericin B and azole drugs were most reported being used. Nine prior reported since 1977 used Amhotericin B [12]. All cases reported after 2004 included voriconazole in their regiment [12] (Figure 8). Smith and Singh were the two prior studies using the same regiment presented in this cacse, Amphotericin B and Fluconazole. Gadgil’s reported management was handled in a similar fashion to ours, with a combination of aggressive surgical debridement and pharmacological therapy. This strategy offers the best chance for success. Curvularia often affects anatomical structures adjacent to the eye, which can sometimes limit debridement. Many cases within the literature report keratitis [14]. In this case, surgical decompression of the optic nerve was warranted. Fortunately, vision remained stable immediately following surgery. Aside from ocular complications, Curvularia has commonly been reported to infect the lungs [7]. The multi-organ involvement necessitates collaboration amongst specialties. In our case, we acquired imaging of the chest and a full ophthalmologic evaluation both before and after surgery to rule out any further systemic involvement. Failure to check for pulmonary involvement could potentially cause disease recurrence and sub-optimal outcomes. Future cases should be reported to provide additional insight on epidemiology and management of CNS Curvalaria infections.

SUMMARY

CNS curvularia responds poorly to standard antifungal therapy and no standardized regiment exists [13]. Like prior reported cases [19-21], amphotericin B and voriconazole were chosen to eradicate fungus. This approach combined with aggressive resection offers the best chance for disease free progression.

REFERENCES

1. Gadgil N, Kupferman M, Smitherman S, Fuller GN, Rao G. Curvularia brain abscess. J Clin Neurosci. 2013; 20: 173-175.

2. Revankar SG, Sutton DA, Rinaldi MG. Primary central nervous system phaeohyphomycosis: a review of 101 cases. Clin Infect Dis. 2004; 38: 206-216.

3. Friedman AD, Campos JM, Rorke LB, Bruce DA, Arbeter AM. Fatal recurrent Curvularia brain abscess. J Pediatr. 1981; 99: 413-415.

4. Rohwedder JJ, Simmons JL, Colfer H, Gatmaitan B. Disseminated Curvularia lunata infection in a football player. Arch Intern Med. 1979; 139: 940-941.

5. Pierce NF, Millan JC, Bender BS, Curtis JL. Disseminated Curvularia infection. Additional therapeutic and clinical considerations with evidence of medical cure. Arch Pathol Lab Med. 1986; 110: 959-961.

6. Ebright JR, Chandrasekar PH, Marks S, Fairfax MR, Aneziokoro A, McGinnis MR. Invasive sinusitis and cerebritis due to Curvularia clavata in an immunocompetent adult. Clin Infect Dis. 1999; 28: 687- 689.

7. Carter E, Boudreaux C. Fatal cerebral phaeohyphomycosis due to Curvularia lunata in an immunocompetent patient. J Clin Microbiol. 2004; 42: 5419-5423.

8. Smith T, Goldschlager T, Mott N, Robertson T, Campbell S. Optic atrophy due to Curvularia lunata mucocoele. Pituitary. 2007; 10: 295- 297.

9. Singh H, Irwin S, Falowski S, Rosen M, Kenyoan L, Jungkind D, et al. Curvularia fungi presenting as a large cranial base meningioma: case report. Neurosurgery. 2008; 63: E177; discussion E177.

10.Rinaldi MG, Phillips P, Schwartz JG, Winn RE, Holt GR, Shagets FW, et al. Human Curvularia infections. Report of five cases and review of the literature. Diagn Microbiol Infect Dis. 1987; 6: 27-39.

11.El-Morsy SM, Khafagy YW, El-Naggar MM, Beih AA. Allergic fungal rhinosinusitis: detection of fungal DNA in sinus aspirate using polymerase chain reaction. J Laryngol Otol. 2010; 124: 152-160.

12.Skovrlj B, Haghighi M, Smethurst ME, Caridi J, Bederson JB. Curvularia Abscess of the Brainstem. World Neurosurgery. 2014; 82: 241.e9-241. e13.

13.Berry AJ, Kerkering TM, Giordano AM, Chiancone J. Phaeohyphomycotic sinusitis. Ped Infect Dis. 1984; 3: 150.

14.Ebright JR, Chandrasekar PH, Marks S, Fairfax MR, Aneziokoro A, McGinnis MR. Invasive sinusitis and cerebritis due to Curvularia clavata in an immunocompetent adult. Clin Infect Dis. 1999; 28: 687- 689.

15. Kaufman SM. Curvularia endocarditis following cardiac surgery. J Clin Pathol. 1971; 56: 466-470.

16.Lampert HB, Hutto JH, Donnelly WH, Shulman ST. Pulmonary and cerebral mycetoma caused by Curvularia pallescens. J Pediatr. 1977; 91: 603-605.

17.de la Monte SM, Hutchins GM. Disseminated Curvularia infection. Arch Pathol Lab Med. 1985; 109: 872-874.

18.Gonzales Zamora JA, Varadarajalu Y. Fatal Curvularia brain abscess in a heart and kidney transplant recipient. IDCases. 2019; 17: e00576.

19.Smith T, Goldschlager T, Mott N, Robertson T, Campbell S. Optic atrophy due to Curvularia lunata mucocoele. Pituitary. 2007; 10: 295- 297.

20.Singh H, Irwin S, Falowski S, Rosen M, Kenyon L, Jungkind D, et al. Curvularia fungi presenting as a large cranial base meningioma: case report. Neurosugery. 2008; 63: E177.

Goldman M, Reddy R, Lucke-Wold B, Barpujari A, Cameron M, et al. (2022) Curvularia and the Brain: Case Demonstration of Optimal Management. Arch Emerg Med Crit Care 6(1): 1051.

Received : 13 Jul 2021
Accepted : 15 Aug 2021
Published : 18 Aug 2021
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X