
Mannheimia haemolytica resistance genes of cattle / Hatipoglu et al. ______________________________________________________________
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INTRODUCTION
Bovine respiratory disease (BRD) is a leading cause of illness and
death in beef cattle (Bos taurus) worldwide. Pasteurella multocida and
Mannheimia haemolytica, both of which are Gramโnegative bacteria
naturally residing in the upper respiratory tract, are the primary
๎
๎ญ๎๎ด๎๎ซ๎ฐ๎ญ๎๎๎จ๎ญ๎ด๎ฌ๎๎ฆ๎๎๎ฎ๎๎ซ๎๎ฎ๎จ๎๎๎ฎ๎ฐ๎
๎๎๎๎ฅ๎๎ซ๎๎๎ด๎ฃ๎๎๎ฝ๎ฌ๎๎ฎ๎๎๎
๎ญ๎๎ด๎๎ซ๎ฐ๎ญ๎๎๎ญ๎๎๎๎ญ๎ท๎ฎ๎๎
mild to severe clinical symptoms, especially when cattle are subjected
to various stressors, including environmental, managemental, or
infectious challenges [1, 2, 3].
๎ฝ๎ฌ๎๎๎ฅ๎ฐ๎๎๎ฐ๎๎ฆ๎ฎ๎๎๎
๎ด๎ญ๎ฐ๎๎๎๎๎ฎ๎ท๎จ๎จ๎๎ซ๎ด๎๎ด๎ฌ๎ญ๎ด๎๎๎ท๎ด๎
๎ซ๎๎ญ๎๎ฎ๎๎ญ๎ซ๎๎๎๎ฅ๎ด๎๎๎
polymicrobial, that this disease occurs because of the disruption of
the lung defense system and colonization by opportunistic pathogens
๎
๎
๎๎๎ซ๎๎ฎ๎ฎ๎ฐ๎๎ฆ๎๎ด๎ฌ๎๎๎
๎๎ญ๎๎๎๎๎๎๎๎๎ฅ๎๎๎ฎ๎๎๎๎๎๎ฌ๎ญ๎๎ฐ๎ฎ๎๎ฎ๎๎๎ฝ๎ฌ๎๎๎๎๎ฎ๎ด๎๎จ๎ซ๎๎๎ฐ๎๎๎๎ด๎
๎ฅ๎๎ญ๎ด๎ท๎ซ๎๎๎๎ฅ๎๎ฎ๎๎
๎๎ซ๎๎๎จ๎๎๎ท๎๎๎๎ฐ๎ญ๎๎ฐ๎๎๎๎ญ๎ด๎ด๎๎๎๎ฐ๎ฎ๎๎ฐ๎๎ด๎๎๎ฎ๎๎๎
ฅ๎
๎ซ๎ฐ๎๎๎๎
๎ท๎๎ญ๎ด๎ฐ๎๎๎
into the alveoli. Although direct effects of lipopolysaccharides on
endothelial cells partly cause this condition, macrophageโderived
๎ฐ๎๎ฅ๎๎ญ๎๎๎ญ๎ด๎๎ซ๎
๎๎๎๎๎ฐ๎ญ๎ด๎๎ซ๎ฎ๎๎ฎ๎ท๎๎ฌ๎๎ญ๎ฎ๎๎ฝ๎๎น๎ฏฮฑ also play an important
๎ซ๎๎๎๎๎๎ฝ๎ฌ๎๎๎ท๎ฎ๎๎๎๎ฅ๎๎ญ๎๎ซ๎๎
๎ฐ๎๎๎ญ๎๎๎๎๎ฐ๎๎ซ๎๎ญ๎๎ซ๎๎จ๎ฌ๎ฐ๎๎ฐ๎๎๎๎ท๎๎ด๎ท๎ซ๎๎ฎ๎๎ด๎๎๎๎๎ด๎๎ซ๎๎ฐ๎๎๎
๎ด๎ฌ๎๎๎ฎ๎จ๎๎๎ฐ๎
ฅ๎๎๎๎ด๎ฐ๎๎๎๎ฆ๎
๎๎ฐ๎ฎ๎๎ท๎ฎ๎ท๎ญ๎๎๎
๎๎ฎ๎ท๎๎๎๎ฎ๎ฎ๎ฅ๎ท๎๎๎ท๎๎๎๎ฎ๎ฎ๎๎ด๎ฌ๎๎๎ญ๎๎ฐ๎๎ญ๎๎ฎ๎๎ญ๎ซ๎๎
treated with antimicrobial drugs. Subacute or chronic cases are
often colonized by opportunistic bacteria, and the primary bacterial
cause may no longer be found. Immunohistochemical (IHC) is used to
diagnose M. haemolytica๎๎๎ฝ๎ฌ๎๎๎๎พ๎๎๎๎๎ด๎ฌ๎๎๎๎๎ญ๎๎๎ญ๎๎ฎ๎๎๎
๎๎๎ท๎ฎ๎๎๎๎ฐ๎๎๎๎ญ๎ฎ๎๎ฎ๎
where fresh tissue is not available, in archival tissues, in cases of
autolysis and antimicrobial treatment. Serum antibody detection
against M. haemolytica๎๎ท๎ฎ๎ฐ๎๎ฆ๎๎๎๎ท๎๎๎ด๎๎
๎ฐ๎๎๎๎๎ท๎ด๎ซ๎ญ๎๎ฐ๎
ก๎ญ๎ด๎ฐ๎๎๎๎ด๎๎ฎ๎ด๎๎๎ง๎๎๎ท๎๎
method and bacterial agglutination test are common research tools.
๎พ๎๎
๎๎
๎๎ซ๎๎๎ด๎ฌ๎๎ฎ๎๎๎ญ๎ซ๎๎๎๎ฅ๎๎๎ฐ๎๎ฐ๎ด๎๎๎๎ท๎ฎ๎๎๎ฐ๎๎๎
ฅ๎๎๎๎๎ฎ๎ด๎ท๎๎ฐ๎๎ฎ๎๎ซ4].
๎น๎๎ซ๎๎
๎๎ญ๎ซ๎ฎ๎๎๎๎ฐ๎๎ฐ๎๎ญ๎๎๎ฐ๎๎ฌ๎ฐ๎
๎ฐ๎ด๎ฐ๎๎๎๎๎๎๎๎๎๎ด๎ซ๎ญ๎ด๎ฐ๎๎๎๎ง๎๎๎๎จ๎๎๎ฅ๎๎ญ๎๎ด๎ฐ๎๎ฐ๎๎ซ๎๎
๎ฐ๎ญ๎๎
drugs has been measured by tube dilution and disc diffusion (Kirby
Bauer) techniques to determine antibiotic resistance [5]. However,
the inability to isolate the target bacteria from the samples taken
from antibiotic treated or autolytic tissues and the length of the test
periods are considered as limiting factors for the use of these tests [6].
๎ฝ๎๎๎๎๎ด๎๎ซ๎๎ฐ๎๎๎๎ด๎ฌ๎๎๎ซ๎๎ฎ๎ฐ๎ฎ๎ด๎ญ๎๎๎๎๎๎ฅ๎M. haemolytica against 14โ, 15โ, and
๎ ๎ฅ๎ฏ๎๎๎๎
๎๎ซ๎๎๎๎๎ญ๎๎ซ๎๎๎ฐ๎๎๎ฎ๎๎
๎ฐ๎ญ๎๎ด๎ฌ๎๎๎ฑ๎๎ด๎๎๎๎ด๎ฌ๎๎๎๎๎ฎ๎จ๎๎๎ฐ๎
ฅ๎๎๎ซ๎๎ฎ๎ฐ๎ฎ๎ด๎ญ๎๎๎๎
๎ฆ๎๎๎๎ฎ๎๎ฌ๎ญ๎
๎๎๎
๎๎๎๎๎ฐ๎๎๎๎ด๎ฐ๎
ฅ๎๎๎๎ซ7]. Whole genome sequencing of the
bacteria has revealed that these resistance phenotypes result from
the combination of at least three distinct macrolide resistance
๎๎๎๎ฌ๎ญ๎๎ฐ๎ฎ๎๎ฎ๎๎๎๎๎๎ด๎ฌ๎๎๎
ฅ๎ซ๎ฎ๎ด๎๎ฆ๎ซ๎๎ท๎จ๎๎๎ฅ๎๎ฐ๎ฎ๎๎๎ญ๎ด๎๎ฎ๎๎๎ด๎ฌ๎๎๎๎ซ๎
๎ด๎ฌ๎ซ๎๎๎
๎๎ฐ๎๎๎ซ๎๎ฎ๎ฐ๎ฎ๎ด๎ญ๎๎๎๎
methyltransferase gene (erm (42)๎จ๎๎ฐ๎ฎ๎๎ด๎ฌ๎๎๎๎๎ด๎๎ซ๎๎ฐ๎๎ญ๎๎ด๎๎๎ฝ๎ฌ๎ฐ๎ฎ๎๎ฆ๎๎๎๎
๎๎๎๎ฅ๎๎ซ๎ฎ๎๎ด๎ฌ๎๎๎๎๎ท๎๎๎ง๎๎ญ๎๎ซ๎๎๎ฐ๎๎๎๎๎๎ฐ๎๎๎๎ฎ๎ญ๎๎ฐ๎๎๎๎๎ญ๎๎๎๎ฎ๎ด๎ซ๎๎จ๎ด๎๎ฆ๎ซ๎ญ๎๎ฐ๎๎๎๎จ๎๎ด๎
๎จ๎๎
I phenotype, with high resistance to lincosamides and low to moderate
resistance to macrolides and streptogramin B. Conformational changes
๎ฐ๎๎๎ด๎ฌ๎๎๎ฑ๎๎ซ๎๎ฆ๎ฐ๎๎๎๎๎ฅ๎๎ซ๎ด๎๎๎๎จ๎ซ๎๎
๎๎๎ด๎๎๎ญ๎๎ซ๎๎๎ฐ๎๎๎๎
๎ฐ๎๎๎ฐ๎๎ฆ๎๎ญ๎๎๎๎๎๎ฐ๎๎ฐ๎๎ญ๎ด๎๎๎ด๎ฌ๎๎
inhibitory effect of macrolides on protein synthesis [8๎ฌ๎๎๎ฝ๎ฌ๎๎๎ฎ๎๎๎๎๎๎
group of isolates contains neither an erm gene nor methylation at
nucleotide A2058 and is resistant to macrolides without associated
๎๎ฐ๎๎๎๎ฎ๎ญ๎๎ฐ๎๎๎๎ซ๎๎ฎ๎ฐ๎ฎ๎ด๎ญ๎๎๎๎๎๎ฝ๎ฌ๎ฐ๎ฎ๎๎ฆ๎ซ๎๎ท๎จ๎๎ฌ๎ญ๎ซ๎
๎๎ซ๎ฎ๎๎ด๎
๎๎๎ซ๎๎ฎ๎ฐ๎ฎ๎ด๎ญ๎๎๎๎๎ฆ๎๎๎๎ฎ, msr
(E) and mph (E),๎๎
๎ฌ๎ฐ๎๎ฌ๎๎ญ๎ซ๎๎๎ฎ๎๎ช๎ท๎๎๎๎๎๎๎ญ๎๎๎๎๎
๎จ๎ซ๎๎ฎ๎ฎ๎๎๎๎ฅ๎ซ๎๎๎๎ด๎ฌ๎๎๎ฎ๎ญ๎๎๎
๎ฎ๎๎ท๎ซ๎๎๎๎๎๎๎๎๎๎ฐ๎๎ฆ๎๎ญ๎๎๎ญ๎๎ซ๎๎๎ฐ๎๎๎๎๎
ฉ๎ท๎
๎๎จ๎ท๎๎จ๎๎ญ๎๎๎๎๎ญ๎๎ซ๎๎๎ฐ๎๎๎๎ฐ๎๎ญ๎๎ด๎ฐ๎
๎ญ๎ด๎ฐ๎๎๎
๎จ๎ฌ๎๎ฎ๎จ๎ฌ๎๎ด๎ซ๎ญ๎๎ฎ๎ฅ๎๎ซ๎ญ๎ฎ๎๎๎๎ซ๎๎ฎ๎จ๎๎๎ด๎ฐ๎
๎๎๎
๎๎๎ฝ๎ฌ๎๎๎ด๎ฌ๎ฐ๎ซ๎๎๎ฆ๎ซ๎๎ท๎จ๎๎๎ฅ๎๎ฐ๎ฎ๎๎๎ญ๎ด๎๎ฎ๎๎๎ฐ๎ฎ๎จ๎๎ญ๎
๎ฎ๎
high resistance to a wide range of macrolides and carries three
determinants: erm (42), msr (E), and mph (E) [7].
Studies conducted in many countries have shown that resistance to
macrolide group antibiotics has developed in M. haemoltica, suggesting
that this resistance may be regional. In our geography, it has been
observed that many antibiotics, especially macrolide group antibiotics,
are used for respiratory system diseases in cattle, but mostly no
response to treatment is received. Although there have been some
studies on the antibiotic sensitivity and resistance of M. haemolytica
๎ฐ๎๎๎๎ท๎ซ๎๎๎๎ท๎๎ด๎ซ๎
๎๎๎ด๎ฌ๎๎ซ๎๎๎ฌ๎ญ๎ฎ๎๎๎๎ด๎๎
๎๎๎๎๎ญ๎๎ฎ๎ด๎ท๎๎
๎๎ฎ๎จ๎๎๎ฐ๎
ฅ๎๎ญ๎๎๎
๎๎ฐ๎๎
๎๎ฎ๎ด๎ฐ๎ฆ๎ญ๎ด๎ฐ๎๎ฆ๎
macrolide group antibiotics and the resistance genes formed against
๎ด๎ฌ๎๎๎๎๎ฝ๎ฌ๎๎๎ฅ๎ญ๎๎ด๎๎ด๎ฌ๎ญ๎ด๎๎ด๎ฌ๎๎๎ญ๎๎ญ๎๎๎๎ฎ๎ฐ๎ฎ๎๎ฐ๎๎ฅ๎๎ซ๎๎ญ๎ด๎ฐ๎๎๎๎๎
๎ด๎ญ๎ฐ๎๎๎๎๎ฅ๎ซ๎๎๎๎ด๎ฌ๎๎
๎ญ๎๎ฐ๎๎ญ๎๎๎๎
๎๎๎ซ๎ฎ๎๎๎ฅ๎๎ด๎ฌ๎๎๎
ฅ๎
๎ซ๎ฐ๎๎๎ท๎ฎ๎๎จ๎๎๎ท๎๎๎๎ฐ๎ญ๎๎๎ญ๎ฎ๎๎ฎ๎๎
๎ซ๎๎ท๎ฆ๎ฌ๎ด๎๎ด๎๎๎จ๎ญ๎ด๎ฌ๎๎๎๎ฆ๎
๎
department indicates that there is no improvement despite antibiotic
treatment also suggests that antibiotic resistance may develop.
In this study, it was aimed to diagnose the presence of M. haemolytica
๎
๎
๎๎๎พ๎๎๎๎๎ด๎ฌ๎๎๎๎ฅ๎ซ๎๎๎๎จ๎ญ๎ซ๎ญ๎
จ๎๎๎
๎๎๎๎๎ฎ๎๎จ๎ซ๎๎จ๎ญ๎ซ๎๎๎๎ฅ๎ซ๎๎๎๎๎ท๎๎ฆ๎๎ด๎ฐ๎ฎ๎ฎ๎ท๎๎๎ฎ๎ญ๎๎จ๎๎๎ฎ๎
of young and adult cattle, and calves brought to pathology department
and also to identify erm (42), msr (E) and mph (E) genes, which are mostly
detected in P. multocida but recently detected in M. haemolytica, by PCR
method. As a result of this study, it is intended to make an important
contribution to the treatment plan of the disease by both diagnosing
M. haemolytica and determining the macrolide resistance genes from
๎ด๎ฌ๎๎๎
ฅ๎
๎ซ๎ฐ๎๎๎ท๎ฎ๎๎จ๎๎๎ท๎๎๎๎ฐ๎ญ๎๎๎ญ๎ฎ๎๎ฎ๎๎๎๎ด๎๎๎ด๎๎๎in cattle.
MATERIALS AND METHODS
Ethical statement
๎ฝ๎ฌ๎๎๎๎ด๎ฌ๎ฐ๎๎ฎ๎๎๎๎๎๎ฐ๎ด๎ด๎๎๎๎๎ฅ๎๎ด๎ฌ๎๎๎น๎ญ๎๎ท๎๎ด๎
๎๎๎ฅ๎๎๎๎ด๎๎ซ๎ฐ๎๎ญ๎ซ๎
๎๎๎๎๎ฐ๎๎ฐ๎๎๎๎
๎ง๎
๎จ๎๎ซ๎ฐ๎๎๎๎ด๎ญ๎๎๎๎๎ฐ๎๎ญ๎๎๎ฑ๎ซ๎๎๎ท๎๎ด๎ฐ๎๎๎๎ญ๎๎๎๎ด๎๎ฎ๎๎ญ๎ซ๎๎ฌ๎๎๎๎๎ด๎๎ซ๎๎๎ท๎๎๎๎ท๎๎
๎๎๎ฐ๎
๎๎ซ๎ฎ๎ฐ๎ด๎
๎๎๎๎๎๎
๎ญ๎๎๎ฝ๎ผ๎ซ๎๎ฐ๎
๎๎๎๎ญ๎จ๎จ๎ซ๎๎
๎๎๎๎ด๎ฌ๎ฐ๎ฎ๎๎ฎ๎ด๎ท๎๎
๎๎ง๎๎จ๎จ๎ซ๎๎
๎ญ๎๎no: 2017/64).
Animals, study area, period and design
๎ฝ๎ฌ๎๎๎๎ญ๎ด๎๎ซ๎ฐ๎ญ๎๎๎๎ฅ๎๎ด๎ฌ๎๎๎ฎ๎ด๎ท๎๎
๎๎๎๎๎ฎ๎ฐ๎ฎ๎ด๎๎๎๎๎ฅ๎๎ญ๎๎ด๎๎ด๎ญ๎๎๎๎ฅ๎๎ ๎๎๎๎
๎๎
๎ฐ๎๎๎๎ญ๎๎ฐ๎๎ญ๎๎ฎ๎
(55 calves [less than 6 months old], 32 young cattle [6โ24 months old]
and 13 adult cattle [older than 24 months old]) that were brought to
๎ด๎ฌ๎๎๎ฃ๎๎จ๎ญ๎ซ๎ด๎๎๎๎ด๎๎๎ฅ๎๎ฑ๎ญ๎ด๎ฌ๎๎๎๎ฆ๎
๎๎๎น๎ญ๎๎ท๎๎ด๎
๎๎๎ฅ๎๎๎๎ด๎๎ซ๎ฐ๎๎ญ๎ซ๎
๎๎๎๎๎ฐ๎๎ฐ๎๎๎๎๎ท๎๎๎๎ท๎๎
๎๎๎ฐ๎
๎๎ซ๎ฎ๎ฐ๎ด๎
๎๎๎๎๎๎
๎ญ๎๎๎ฝ๎ผ๎ซ๎๎ฐ๎
๎๎๎๎
๎๎ด๎
๎๎๎๎๎ก๎๎ ๎ก๎๎ญ๎๎๎๎ก๎๎ ๎ฆ๎๎ฅ๎๎ซ๎๎๎๎๎ซ๎๎จ๎ฎ๎
๎๎ญ๎๎๎
๎๎ฐ๎ญ๎ฆ๎๎๎ฎ๎๎๎๎ญ๎ฎ๎๎
ฅ๎
๎ซ๎ฐ๎๎๎ท๎ฎ๎๎จ๎๎๎ท๎๎๎๎ฐ๎ญ๎๎๎ฝ๎ฌ๎๎๎๎ฐ๎ญ๎ฆ๎๎๎ฎ๎ด๎ฐ๎๎๎๎ซ๎ฐ๎ด๎๎ซ๎ฐ๎ญ๎๎๎ฅ๎๎
ฅ๎
๎ซ๎ฐ๎๎๎ท๎ฎ๎
๎จ๎๎๎ท๎๎๎๎ฐ๎ญ๎๎
๎๎ซ๎๎๎๎๎ด๎๎ซ๎๎ฐ๎๎๎๎๎ญ๎๎๎๎ซ๎๎ฐ๎๎ฆ๎๎ด๎๎๎ด๎ฌ๎๎๎
ฅ๎๎๎ฐ๎๎ฆ๎ฎ๎๎๎๎ฎ๎๎ซ๎ฐ๎
๎๎๎
in the Results. All animals were routinely necropsied, and tissue
๎ฎ๎ญ๎๎จ๎๎๎ฎ๎๎
๎๎ซ๎๎๎ด๎ญ๎๎๎๎๎ฅ๎๎ซ๎๎ฌ๎ฐ๎ฎ๎ด๎๎จ๎ญ๎ด๎ฌ๎๎๎๎ฆ๎ฐ๎๎ญ๎๎๎ญ๎๎๎๎๎พ๎๎๎๎
๎ญ๎๎ฐ๎๎ญ๎ด๎ฐ๎๎๎ฎ๎๎ญ๎ฅ๎ด๎๎ซ๎
macroscopic inspection.
Histopathological method
๎๎ท๎๎ฆ๎๎ฎ๎ญ๎๎จ๎๎๎ฎ๎๎ด๎ญ๎๎๎๎๎ฅ๎ซ๎๎๎๎๎๎๎ซ๎๎จ๎ฎ๎ฐ๎๎๎๎ซ๎ท๎๎ฐ๎๎ญ๎๎ด๎ฎ๎๎
๎๎ซ๎๎๎
ฅ๎
๎๎๎๎ฐ๎๎
๎ ๎๎ฆ๎๎
๎ท๎ฅ๎ฅ๎๎ซ๎๎๎๎ฅ๎๎ซ๎๎ญ๎๎๎๎ฌ๎
๎๎๎๎ฎ๎๎๎ท๎ด๎ฐ๎๎๎๎ญ๎๎๎๎๎๎
๎๎๎๎๎๎๎ฐ๎๎๎จ๎ญ๎ซ๎ญ๎
จ๎๎๎ญ๎ฅ๎ด๎๎ซ๎
๎ซ๎๎ท๎ด๎ฐ๎๎๎๎ด๎ฐ๎ฎ๎ฎ๎ท๎๎๎จ๎ซ๎๎๎๎ฎ๎ฎ๎ฐ๎๎ฆ๎๎จ๎ซ๎๎๎๎๎ท๎ซ๎๎ฎ๎๎๎ฝ๎ฌ๎๎๎ด๎ฐ๎ฎ๎ฎ๎ท๎๎๎ฎ๎ญ๎๎จ๎๎๎ฎ๎๎
๎๎ซ๎๎
sectioned at a thickness of 5 ฮผ๎๎๎๎๎๎ญ๎๎๎ฐ๎๎ซ๎๎ด๎๎๎๎๎ง๎๎๎ฐ๎๎ญ๎๎ด๎๎๎ก๎ ๎ก๎ค๎ด๎ฝ๎๎
๎บ๎๎ซ๎๎ญ๎๎
๎จ๎๎๎ฎ๎ด๎ญ๎ฐ๎๎๎๎๎
๎ฐ๎ด๎ฌ๎๎พ๎ญ๎๎๎๎ด๎๎
๎
๎๎๎๎๎ช๎ง๎๎ฎ๎ฐ๎๎๎ง๎พ๎ช๎ง๎จ๎๎ญ๎๎๎๎๎
๎ญ๎๎ฐ๎๎๎๎
๎ท๎๎๎๎ซ๎๎ญ๎๎
๎ฐ๎๎๎๎ท๎๎ญ๎ซ๎๎๎ฐ๎ฆ๎ฌ๎ด๎๎๎ฐ๎๎ซ๎๎ฎ๎๎๎จ๎๎๎ง๎๎๎
๎๎จ๎ท๎ฎ๎๎๎๎ค๎ ๎๎๎ฝ๎๎๎
๎๎๎๎๎ญ๎จ๎ญ๎๎จ๎๎
Photographs were taken of the lesions observed during microscopic
๎๎
๎ญ๎๎ฐ๎๎ญ๎ด๎ฐ๎๎๎๎ง๎๎๎
๎๎จ๎ท๎ฎ๎๎ฃ๎ฑ๎ ๎ก๎๎๎ฝ๎๎๎
๎๎๎๎๎ญ๎จ๎ญ๎๎จ๎
Immunohistochemical method
๎น๎๎ซ๎๎ด๎ฌ๎๎๎๎พ๎๎๎๎๎ด๎ฌ๎๎๎๎๎ฎ๎๎๎ด๎ฐ๎๎๎ฎ๎๎ด๎ญ๎๎๎๎๎ฅ๎ซ๎๎๎๎ด๎ฌ๎๎๎๎ท๎๎ฆ๎๎ด๎ฐ๎ฎ๎ฎ๎ท๎๎ฎ๎๎๎๎๎ค๎ฮผm
๎ด๎ฌ๎ฐ๎๎๎๎ด๎๎๎ญ๎๎ฌ๎๎ฎ๎ฐ๎
๎๎๎ฎ๎๎ฐ๎๎๎ฎ๎๎
๎๎ซ๎๎๎ฎ๎ด๎ญ๎ฐ๎๎๎๎๎ง๎ฑ๎๎ซ๎๎
๎ฐ๎๎ญ๎ฎ๎๎๎๎๎๎๎๎๎๎ฑ๎ซ๎๎ด๎๎ฐ๎๎๎๎๎๎๎๎๎
๎ฑ๎๎ฎ๎ด๎๎ฑ๎ซ๎ฐ๎๎๎ซ๎๎๎ฑ๎๎๎
๎๎๎ซ๎๎๎ฃ๎๎๎๎๎ฃ๎๎๎๎๎พ๎๎๎ญ๎ด๎๎
๎
๎๎ฐ๎๎จ๎๎ฐ๎๎๎ญ๎๎ฅ๎ท๎๎๎
๎๎ญ๎ท๎ด๎๎๎ญ๎ด๎ฐ๎๎๎๎พ๎๎
๎ง๎๎๎ฐ๎๎ญ๎๎๎๎๎๎๎ญ๎
๎จ๎๎๎ฐ๎ด๎๎จ๎ซ๎๎๎๎๎ท๎ซ๎๎๎๎ฃ๎๎ด๎ญ๎ฐ๎๎ฎ๎๎๎ฅ๎๎ด๎ฌ๎๎๎ฎ๎ด๎ญ๎ฐ๎๎ฐ๎๎ฆ๎๎จ๎ซ๎๎ด๎๎๎๎๎ฎ๎๎
๎ฐ๎ด๎ฌ๎
๎๎ญ๎๎ฌ๎๎จ๎ซ๎ฐ๎๎ญ๎ซ๎
๎๎ญ๎๎ด๎ฐ๎
๎๎๎
๎๎ญ๎๎๎๎ด๎ฌ๎๎๎ญ๎จ๎จ๎๎ฐ๎๎ญ๎ด๎ฐ๎๎๎ฎ๎๎ญ๎ซ๎๎๎ฎ๎ฌ๎๎
๎๎๎ฐ๎๎๎ฝ๎๎๎๎ง๎๎๎๎
๎ท๎ด๎ญ๎ฐ๎๎๎๎๎ฎ๎๎๎ด๎ฐ๎๎๎ฎ๎๎๎ฅ๎๎๎พ๎๎๎
๎๎ซ๎๎๎๎
๎ญ๎๎ฐ๎๎๎๎๎ท๎๎๎๎ซ๎๎ญ๎๎
๎ฐ๎๎๎๎ท๎๎ญ๎ซ๎๎๎ฐ๎ฆ๎ฌ๎ด๎
๎๎ฐ๎๎ซ๎๎ฎ๎๎๎จ๎๎๎ง๎๎๎
๎๎จ๎ท๎ฎ๎๎๎๎ค๎ ๎๎๎ฝ๎๎๎
๎๎๎๎๎ญ๎จ๎ญ๎๎จ๎๎ญ๎๎๎๎ด๎ฌ๎๎๎๎ซ๎ฐ๎ด๎๎ซ๎ฐ๎ญ๎๎๎ฅ๎๎จ๎๎ฎ๎ฐ๎ด๎ฐ๎
๎๎
IHC staining determined by pathologists.