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1.
Commun Biol ; 6(1): 360, 2023 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-37012403

RESUMO

HMG-CoA reductase (HMGR), a rate-limiting enzyme of the mevalonate pathway in Gram-positive pathogenic bacteria, is an attractive target for development of novel antibiotics. In this study, we report the crystal structures of HMGR from Enterococcus faecalis (efHMGR) in the apo and liganded forms, highlighting several unique features of this enzyme. Statins, which inhibit the human enzyme with nanomolar affinity, perform poorly against the bacterial HMGR homologs. We also report a potent competitive inhibitor (Chembridge2 ID 7828315 or compound 315) of the efHMGR enzyme identified by a high-throughput, in-vitro screening. The X-ray crystal structure of efHMGR in complex with 315 was determined to 1.27 Å resolution revealing that the inhibitor occupies the mevalonate-binding site and interacts with several key active site residues conserved among bacterial homologs. Importantly, 315 does not inhibit the human HMGR. Our identification of a selective, non-statin inhibitor of bacterial HMG-CoA reductases will be instrumental in lead optimization and development of novel antibacterial drug candidates.


Assuntos
Enterococcus faecalis , Inibidores de Hidroximetilglutaril-CoA Redutases , Humanos , Acil Coenzima A/metabolismo , Enterococcus faecalis/enzimologia , Inibidores de Hidroximetilglutaril-CoA Redutases/química , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Ácido Mevalônico
2.
Biochemistry ; 52(31): 5195-205, 2013 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-23802607

RESUMO

In this study, we take advantage of the ability of HMG-CoA reductase (HMGR) from Pseudomonas mevalonii to remain active while in its crystallized form to study the changing interactions between the ligands and protein as the first reaction intermediate is created. HMG-CoA reductase catalyzes one of the few double oxidation-reduction reactions in intermediary metabolism that take place in a single active site. Our laboratory has undertaken an exploration of this reaction space using structures of HMG-CoA reductase complexed with various substrate, nucleotide, product, and inhibitor combinations. With a focus in this publication on the first hydride transfer, our structures follow this reduction reaction as the enzyme converts the HMG-CoA thioester from a flat sp(2)-like geometry to a pyramidal thiohemiacetal configuration consistent with a transition to an sp(3) orbital. This change in the geometry propagates through the coenzyme A (CoA) ligand whose first amide bond is rotated 180° where it anchors a web of hydrogen bonds that weave together the nucleotide, the reaction intermediate, the enzyme, and the catalytic residues. This creates a stable intermediate structure prepared for nucleotide exchange and the second reduction reaction within the HMG-CoA reductase active site. Identification of this reaction intermediate provides a template for the development of an inhibitor that would act as an antibiotic effective against the HMG-CoA reductase of methicillin-resistant Staphylococcus aureus.


Assuntos
Acil Coenzima A/química , Proteínas de Bactérias/química , Coenzima A/química , Pseudomonas/enzimologia , Acil Coenzima A/genética , Acil Coenzima A/metabolismo , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Catálise , Domínio Catalítico , Coenzima A/metabolismo , Cinética , Modelos Moleculares , Pseudomonas/química , Pseudomonas/genética
3.
Biochemistry ; 45(48): 14407-14, 2006 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-17128980

RESUMO

Recent structural studies of the HMG-CoA synthase members of the thiolase superfamily have shown that the catalytic loop containing the nucleophilic cysteine follows the phi and psi angle pattern of a II' beta turn. However, the i + 1 residue is conserved as an alanine, which is quite unusual in this position as it must adopt a strained positive phi angle to accommodate the geometry of the turn. To assess the effect of the conserved strain in the catalytic loop, alanine 110 of Enterococcus faecalis 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) synthase was mutated to a glycine. Subsequent enzymatic studies showed that the overall reaction rate of the enzyme was increased 140-fold. An X-ray crystallographic study of the Ala110Gly mutant enzyme demonstrated unanticipated adjustments in the active site that resulted in additional stabilization of all three steps of the reaction pathway. The rates of acetylation and hydrolysis of the mutant enzyme increased because the amide nitrogen of Ser308 shifts 0.4 A toward the catalytic cysteine residue. This motion positions the nitrogen to better stabilize the intermediate negative charge that develops on the carbonyl oxygen of the acetyl group during both the formation of the acyl-enzyme intermediate and its hydrolysis. In addition, the hydroxyl of Ser308 rotates 120 degrees to a position where it is able to stabilize the carbanion intermediate formed by the methyl group of the acetyl-S-enzyme during its condensation with acetoacetyl-CoA.


Assuntos
Hidroximetilglutaril-CoA Sintase/química , Hidroximetilglutaril-CoA Sintase/metabolismo , Acetilcoenzima A/metabolismo , Cristalografia por Raios X , Dimerização , Enterococcus faecalis/enzimologia , Enterococcus faecalis/genética , Expressão Gênica , Hidrólise , Hidroximetilglutaril-CoA Sintase/genética , Hidroximetilglutaril-CoA Sintase/isolamento & purificação , Cinética , Modelos Moleculares , Mutação/genética , Estrutura Quaternária de Proteína , Estrutura Secundária de Proteína
4.
Biochemistry ; 44(43): 14256-67, 2005 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-16245942

RESUMO

Biosynthesis of the isoprenoid precursor, isopentenyl diphosphate, is a critical function in all independently living organisms. There are two major pathways for this synthesis, the non-mevalonate pathway found in most eubacteria and the mevalonate pathway found in animal cells and a number of pathogenic bacteria. An early step in this pathway is the condensation of acetyl-CoA and acetoacetyl-CoA into HMG-CoA, catalyzed by the enzyme HMG-CoA synthase. To explore the possibility of a small molecule inhibitor of the enzyme functioning as a non-cell wall antibiotic, the structure of HMG-CoA synthase from Enterococcus faecalis (MVAS) was determined by selenomethionine MAD phasing to 2.4 A and the enzyme complexed with its second substrate, acetoacetyl-CoA, to 1.9 A. These structures show that HMG-CoA synthase from Enterococcus is a member of the family of thiolase fold enzymes and, while similar to the recently published HMG-CoA synthase structures from Staphylococcus aureus, exhibit significant differences in the structure of the C-terminal domain. The acetoacetyl-CoA binary structure demonstrates reduced coenzyme A and acetoacetate covalently bound to the active site cysteine through a thioester bond. This is consistent with the kinetics of the reaction that have shown acetoacetyl-CoA to be a potent inhibitor of the overall reaction, and provides a starting point in the search for a small molecule inhibitor.


Assuntos
Acil Coenzima A/metabolismo , Enterococcus faecalis/enzimologia , Hidroximetilglutaril-CoA Sintase/química , Acetoacetatos/química , Acil Coenzima A/antagonistas & inibidores , Sítios de Ligação , Catálise , Cristalografia por Raios X/métodos , Cisteína/química , Hidroximetilglutaril-CoA Sintase/metabolismo , Cinética , Modelos Moleculares , Dados de Sequência Molecular , Selenometionina/química , Alinhamento de Sequência , Especificidade por Substrato
5.
Protein Sci ; 14(5): 1134-9, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15802646

RESUMO

The six enzymes of the mevalonate pathway of isopentenyl diphosphate biosynthesis represent potential for addressing a pressing human health concern, the development of antibiotics against resistant strains of the Gram-positive streptococci. We previously characterized the first four of the mevalonate pathway enzymes of Enterococcus faecalis, and here characterize the fifth, phosphomevalonate kinase (E.C. 2.7.4.2). E. faecalis genomic DNA and the polymerase chain reaction were used to clone DNA thought to encode phosphomevalonate kinase into pET28b(+). Double-stranded DNA sequencing verified the sequence of the recombinant gene. The encoded N-terminal hexahistidine-tagged protein was expressed in Escherichia coli with induction by isopropylthiogalactoside and purified by Ni(++) affinity chromatography, yield 20 mg protein per liter. Analysis of the purified protein by MALDI-TOF mass spectrometry established it as E. faecalis phosphomevalonate kinase. Analytical ultracentrifugation revealed that the kinase exists in solution primarily as a dimer. Assay for phosphomevalonate kinase activity used pyruvate kinase and lactate dehydrogenase to couple the formation of ADP to the oxidation of NADH. Optimal activity occurred at pH 8.0 and at 37 degrees C. The activation energy was approximately 5.6 kcal/mol. Activity with Mn(++), the preferred cation, was optimal at about 4 mM. Relative rates using different phosphoryl donors were 100 (ATP), 3.6 (GTP), 1.6 (TTP), and 0.4 (CTP). K(m) values were 0.17 mM for ATP and 0.19 mM for (R,S)-5-phosphomevalonate. The specific activity of the purified enzyme was 3.9 micromol substrate converted per minute per milligram protein. Applications to an immobilized enzyme bioreactor and to drug screening and design are discussed.


Assuntos
Enterococcus faecalis/enzimologia , Fosfotransferases (Aceptor do Grupo Fosfato)/metabolismo , Sequência de Aminoácidos , Cátions Bivalentes , Cromatografia de Afinidade , Cinética , Dados de Sequência Molecular , Fosfotransferases (Aceptor do Grupo Fosfato)/química , Homologia de Sequência de Aminoácidos , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Temperatura
6.
Genome Biol ; 5(11): 248, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15535874

RESUMO

The enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase catalyzes the conversion of HMG-CoA to mevalonate, a four-electron oxidoreduction that is the rate-limiting step in the synthesis of cholesterol and other isoprenoids. The enzyme is found in eukaryotes and prokaryotes; and phylogenetic analysis has revealed two classes of HMG-CoA reductase, the Class I enzymes of eukaryotes and some archaea and the Class II enzymes of eubacteria and certain other archaea. Three-dimensional structures of the catalytic domain of HMG-CoA reductases from humans and from the bacterium Pseudomonas mevalonii, in conjunction with site-directed mutagenesis studies, have revealed details of the mechanism of catalysis. The reaction catalyzed by human HMG-CoA reductase is a target for anti-hypercholesterolemic drugs (statins), which are intended to lower cholesterol levels in serum. Eukaryotic forms of the enzyme are anchored to the endoplasmic reticulum, whereas the prokaryotic enzymes are soluble. Probably because of its critical role in cellular cholesterol homeostasis, mammalian HMG-CoA reductase is extensively regulated at the transcriptional, translational, and post-translational levels.


Assuntos
Hidroximetilglutaril-CoA Redutases/química , Hidroximetilglutaril-CoA Redutases/fisiologia , Animais , Humanos , Hidroximetilglutaril-CoA Redutases/genética
7.
Biotechnol Bioeng ; 87(4): 546-51, 2004 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-15286992

RESUMO

The five-carbon metabolic intermediate isopentenyl diphosphate constitutes the basic building block for the biosynthesis of all isoprenoids in all forms of life. Two distinct pathways lead from amphibolic intermediates to isopentenyl diphosphate. The Gram-positive cocci and certain other pathogenic bacteria employ exclusively the mevalonate pathway, a set of six enzyme-catalyzed reactions that convert 3 mol of acetyl-CoA to 1 mol each of carbon dioxide and isopentenyl diphosphate. The survival of the Gram-positive cocci requires a fully functional set of mevalonate pathway enzymes. These enzymes therefore represent potential targets of inhibitors that might be employed as antibiotics directed against multidrug-resistant strains of certain bacterial pathogens. A rapid throughput, bioreactor-based assay to assess the effects of potential inhibitors on several enzymes simultaneously should prove useful for the survey of candidate inhibitors. To approach this goal, and as a proof of concept, we employed enzymes from the Gram-positive pathogen Enterococcus faecalis. Purified recombinant enzymes that catalyze the first three reactions of the mevalonate pathway were immobilized in two kinds of continuous flow enzyme bioreactors: a classical hollow fiber bioreactor and an immobilized plug flow bioreactor that exploited a novel method of enzyme immobilization. Both bioreactor types employed recombinant acetoacetyl-CoA thiolase, HMG-CoA synthase, and HMG-CoA reductase from E. faecalis to convert acetyl-CoA to mevalonate, the central intermediate of the mevalonate pathway. Reactor performance was monitored continuously by spectrophotometric measurement of the concentration of NADPH in the reactor effluent. Additional potential applications of an Ni(++) affinity support bioreactor include using recombinant enzymes from extremophiles for biosynthetic applications. Finally, linking a Ni(++) affinity support bioreactor to an HPLC-mass spectrometer would provide an experimental and pedagogical tool for study of metabolite flux and pool sizes of intermediates to model regulation in intact cells.


Assuntos
Acetilcoenzima A/química , Acetil-CoA C-Acetiltransferase/química , Reatores Biológicos , Hemiterpenos/síntese química , Hidroximetilglutaril-CoA Redutases/química , Hidroximetilglutaril-CoA Sintase/química , Ácido Mevalônico/síntese química , Compostos Organofosforados/síntese química , Enterococcus faecalis/enzimologia , Enterococcus faecalis/genética , Ativação Enzimática , Enzimas Imobilizadas/química , Cinética , Complexos Multienzimáticos/química , Proteínas Recombinantes/química
8.
Protein Sci ; 13(6): 1693-7, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15152097

RESUMO

There are two structural classes of HMG-CoA reductase, the third enzyme of the mevalonate pathway of isopentenyl diphosphate biosynthesis-the Class I enzymes of eukaryotes and the Class II enzymes of certain eubacteria. Structural requirements for ligand binding to the Class II HMG-CoA reductase of Pseudomonas mevalonii were investigated. For conversion of mevalonate to HMG-CoA the -CH(3), -OH, and -CH(2)COO(-) groups on carbon 3 of mevalonate were essential for ligand recognition. The statin drug Lovastatin inhibited both the conversion of HMG-CoA to mevalonate and the reverse of this reaction. Inhibition was competitive with respect to HMG-CoA or mevalonate and noncompetitive with respect to NADH or NAD(+). K(i) values were millimolar. The over 10(4)-fold difference in statin K(i) values that distinguishes the two classes of HMG-CoA reductase may result from differences in the specific contacts between the statin and residues present in the Class I enzymes but lacking in a Class II HMG-CoA reductase.


Assuntos
Hidroximetilglutaril-CoA Redutases/metabolismo , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Pseudomonas/enzimologia , Escherichia coli/genética , Expressão Gênica , Hidroximetilglutaril-CoA Redutases/genética , Cinética , Lovastatina/farmacologia , Ácido Mevalônico/análogos & derivados , Ácido Mevalônico/metabolismo , Ácido Mevalônico/farmacologia , Estrutura Molecular
10.
Protein Sci ; 13(3): 687-93, 2004 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-14767074

RESUMO

Gram-positive pathogens synthesize isopentenyl diphosphate, the five-carbon precursor of isoprenoids, via the mevalonate pathway. The enzymes of this pathway are essential for the survival of these organisms, and thus may represent possible targets for drug design. To extend our investigation of the mevalonate pathway in Enterococcus faecalis, we PCR-amplified and cloned into pET-28b the mvaK1 gene thought to encode mevalonate kinase, the fourth enzyme of the pathway. Following transformation of the construct EFK1-pET28b into Escherichia coli BL21(DE3) cells, the expressed C-terminally hexahistidine-tagged protein was purified on a nickel affinity support to apparent homogeneity. The purified protein catalyzed the divalent ion-dependent phosphorylation of mevalonate to mevalonate 5-phosphate. The specific activity of the purified kinase was 24 micromole/min/mg protein. Based on sedimentation velocity data, E. faecalis mevalonate kinase exists in solution primarily as a monomer with a mass of 32.2 kD. Optimal activity occurred at pH 10 and at 37 degrees C. Delta H(a) was 22 kcal/mole. Kinetic analysis suggested that the reaction proceeds via a sequential mechanism. K(m) values were 0.33 mM (mevalonate), 1.1 mM (ATP), and 3.3 mM (Mg(2+)). Unlike mammalian mevalonate kinases, E. faecalis mevalonate kinase utilized all tested nucleoside triphosphates as phosphoryl donors. ADP, but not AMP, inhibited the reaction with a K(i) of 2.7 mM.


Assuntos
Enterococcus faecalis/enzimologia , Fosfotransferases (Aceptor do Grupo Álcool)/química , Difosfato de Adenosina/química , Monofosfato de Adenosina/química , Trifosfato de Adenosina/química , Trifosfato de Adenosina/metabolismo , Proteínas de Bactérias/química , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Ligação Competitiva , Cátions Bivalentes/química , Clonagem Molecular , Eletroforese em Gel de Poliacrilamida , Concentração de Íons de Hidrogênio , Cinética , Ácido Mevalônico/química , Ácido Mevalônico/metabolismo , Peso Molecular , Nucleotídeos/química , Nucleotídeos/metabolismo , Fosfotransferases (Aceptor do Grupo Álcool)/genética , Fosfotransferases (Aceptor do Grupo Álcool)/metabolismo , Proteínas Recombinantes/química , Proteínas Recombinantes/isolamento & purificação , Proteínas Recombinantes/metabolismo , Especificidade por Substrato , Temperatura , Ultracentrifugação
11.
J Biol Chem ; 278(22): 19933-8, 2003 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-12621048

RESUMO

Hydroxymethylglutaryl-CoA (HMG-CoA) reductase is the primary target in the current clinical treatment of hypercholesterolemias with specific inhibitors of the "statin" family. Statins are excellent inhibitors of the class I (human) enzyme but relatively poor inhibitors of the class II enzymes of important bacterial pathogens. To investigate the molecular basis for this difference we determined the x-ray structure of the class II Pseudomonas mevalonii HMG-CoA reductase in complex with the statin drug lovastatin. The structure shows lovastatin bound in the active site and its interactions with residues critically involved in catalysis and substrate binding. Binding of lovastatin also displaces the flap domain of the enzyme, which contains the catalytic residue His-381. Comparison with the structures of statins bound to the human enzyme revealed a similar mode of binding but marked differences in specific interactions that account for the observed differences in affinity. We suggest that these differences might be exploited to develop selective class II inhibitors for use as antibacterial agents against pathogenic microorganisms.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/química , Cristalografia por Raios X , Inibidores de Hidroximetilglutaril-CoA Redutases/metabolismo , Modelos Moleculares , Estrutura Molecular , Ligação Proteica
12.
J Bacteriol ; 184(15): 4065-70, 2002 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12107122

RESUMO

Biosynthesis of the isoprenoid precursor isopentenyl diphosphate (IPP) proceeds via two distinct pathways. Sequence comparisons and microbiological data suggest that multidrug-resistant strains of gram-positive cocci employ exclusively the mevalonate pathway for IPP biosynthesis. Bacterial mevalonate pathway enzymes therefore offer potential targets for development of active site-directed inhibitors for use as antibiotics. We used the PCR and Enterococcus faecalis genomic DNA to isolate the mvaS gene that encodes 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) synthase, the second enzyme of the mevalonate pathway. mvaS was expressed in Escherichia coli from a pET28 vector with an attached N-terminal histidine tag. The expressed enzyme was purified by affinity chromatography on Ni(2+)-agarose to apparent homogeneity and a specific activity of 10 micromol/min/mg. Analytical ultracentrifugation showed that the enzyme is a dimer (mass, 83.9 kDa; s(20,w), 5.3). Optimal activity occurred in 2.0 mM MgCl(2) at 37(o)C. The DeltaH(a) was 6,000 cal. The pH activity profile, optimum activity at pH 9.8, yielded a pK(a) of 8.8 for a dissociating group, presumably Glu78. The stoichiometry per monomer of acetyl-CoA binding was 1.2 +/- 0.2 and that of covalent acetylation was 0.60 +/- 0.02. The K(m) for the hydrolysis of acetyl-CoA was 10 microM. Coupled conversion of acetyl-CoA to mevalonate was demonstrated by using HMG-CoA synthase and acetoacetyl-CoA thiolase/HMG-CoA reductase from E. faecalis.


Assuntos
Antígenos de Bactérias/biossíntese , Coenzima A Ligases/metabolismo , Enterococcus faecalis/enzimologia , Hemiterpenos , Compostos Organofosforados/metabolismo , Acetilcoenzima A/metabolismo , Sequência de Aminoácidos , Animais , Coenzima A Ligases/química , Coenzima A Ligases/genética , Escherichia coli/genética , Vetores Genéticos , Concentração de Íons de Hidrogênio , Hidroximetilglutaril-CoA Sintase , Cinética , Cloreto de Magnésio , Ácido Mevalônico/metabolismo , Dados de Sequência Molecular , Peso Molecular , Proteínas Recombinantes/biossíntese , Temperatura
13.
J Bacteriol ; 184(8): 2116-22, 2002 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11914342

RESUMO

Many bacteria employ the nonmevalonate pathway for synthesis of isopentenyl diphosphate, the monomer unit for isoprenoid biosynthesis. However, gram-positive cocci exclusively use the mevalonate pathway, which is essential for their growth (E. I. Wilding et al., J. Bacteriol. 182:4319-4327, 2000). Enzymes of the mevalonate pathway are thus potential targets for drug intervention. Uniquely, the enterococci possess a single open reading frame, mvaE, that appears to encode two enzymes of the mevalonate pathway, acetoacetyl-coenzyme A thiolase and 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. Western blotting revealed that the mvaE gene product is a single polypeptide in Enterococcus faecalis, Enterococcus faecium, and Enterococcus hirae. The mvaE gene was cloned from E. faecalis and was expressed with an N-terminal His tag in Escherichia coli. The gene product was then purified by nickel affinity chromatography. As predicted, the 86.5-kDa mvaE gene product catalyzed both the acetoacetyl-CoA thiolase and HMG-CoA reductase reactions. Temperature optima, DeltaH(a) and K(m) values, and pH optima were determined for both activities. Kinetic studies of acetoacetyl-CoA thiolase implicated a ping-pong mechanism. CoA acted as an inhibitor competitive with acetyl-CoA. A millimolar K(i) for a statin drug confirmed that E. faecalis HMG-CoA reductase is a class II enzyme. The oxidoreductant was NADP(H). A role for an active-site histidine during the first redox step of the HMG-CoA, reductase reaction was suggested by the ability of diethylpyrocarbonate to block formation of mevalonate from HMG-CoA, but not from mevaldehyde. Sequence comparisons with other HMG-CoA reductases suggest that the essential active-site histidine is His756. The mvaE gene product represents the first example of an HMG-CoA reductase fused to another enzyme.


Assuntos
Acil Coenzima A/fisiologia , Enterococcus faecalis/enzimologia , Hemiterpenos , Hidroximetilglutaril-CoA Redutases/fisiologia , Compostos Organofosforados/metabolismo , Sequência de Aminoácidos , Dietil Pirocarbonato/farmacologia , Enterococcus faecalis/genética , Concentração de Íons de Hidrogênio , Hidroxilamina/farmacologia , Hidroximetilglutaril-CoA Redutases/química , Cinética , Dados de Sequência Molecular , Especificidade por Substrato , Temperatura
14.
México; El Manual Moderno; 9 ed; 1984. 660 p. ilus.
Monografia em Espanhol | LILACS | ID: lil-374110
15.
São Paulo; Atheneu; 5 ed; 1982. 736 p. ilus, tab.
Monografia em Português | LILACS | ID: lil-774092
16.
Sao Paulo; Atheneu; 5 ed; 1982. 736 p. ilus, tab, graf, 27cm.
Monografia em Português | LILACS, HANSEN, Hanseníase, SESSP-ILSLACERVO, Sec. Est. Saúde SP | ID: biblio-1083526
17.
São Paulo; Atheneu; 5 ed; 1982. 736 p. ilus, tab.
Monografia em Português | Sec. Munic. Saúde SP, AHM-Acervo, TATUAPE-Acervo | ID: sms-10725
18.
Los Altos; Lange; 17 ed; 1979. 702 p. graf, tab, 26cm.
Monografia em Inglês | LILACS, HANSEN, Hanseníase, SESSP-ILSLACERVO, Sec. Est. Saúde SP | ID: biblio-1083350
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