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TC(875).(20).Sexology Case No 28. Pubic lice ও Scabies

Pubic lice ও Scabies — Core Clinical Answer বাংলা

প্রথমে পার্থক্য মনে রাখুন:
Pubic lice = pubic hair–এ Phthirus pubis নামের উকুন/lice থাকে।
Scabies = ত্বকের ভিতরে Sarcoptes scabiei var. hominis mite burrow করে।
দুটোতেই চুলকানি হয়, কিন্তু diagnosis ও treatment আলাদা। CDC অনুযায়ী pubic lice সাধারণত sexual contact–এ ছড়ায় এবং scabies close skin-to-skin contact/sexual contact/household contact–এ ছড়াতে পারে।

1. Definition / সংজ্ঞা

A. Pubic lice / Pediculosis pubis / “Crab lice”

Pubic hair বা genital area–এর coarse hair–এ ছোট blood-sucking ectoparasite Phthirus pubis infestation হলে তাকে pubic lice বলে। এটি pubic hair ছাড়াও beard, moustache, axilla, chest hair, eyebrow/eyelash–এ থাকতে পারে।

B. Scabies / খোস-পাঁচড়া

Scabies হলো Sarcoptes scabiei var. hominis mite দ্বারা সৃষ্ট parasitic skin infestation। Female mite epidermis–এর stratum corneum–এ burrow করে egg দেয়; mite, egg ও fecal material–এর বিরুদ্ধে delayed hypersensitivity reaction থেকে intense itching ও rash হয়। WHO scabies–কে intense itching ও rash-causing parasitic infestation হিসেবে বর্ণনা করেছে।

2. Cause / Etiology & Pathophysiology

A. Pubic lice — Cause গুলো

  1. মূল parasite:Phthirus pubis
    • Human blood খেয়ে বেঁচে থাকে।
    • Hair shaft–এর গোড়ার কাছে nit/egg attach করে।
    • Pubic hair–এ বেশি থাকে কারণ coarse hair আঁকড়ে ধরতে পারে।
  2. Transmission / ছড়ানোর পথ
    • প্রধানত sexual contact।
    • Close body contact থেকেও ছড়াতে পারে।
    • Rarely contaminated towel, bedding, underwear থেকে হতে পারে, কিন্তু sexual route বেশি গুরুত্বপূর্ণ।
  3. Poor hygiene নয়
    • Pubic lice হওয়া মানেই অপরিষ্কার থাকা নয়। যেকোনো sexually active adult আক্রান্ত হতে পারে।
  4. Associated STI risk
    • Pubic lice নিজে HIV/syphilis transmit করে না, কিন্তু sexual exposure marker হিসেবে STI screening দরকার হতে পারে। CDC pubic lice থাকলে HIV, syphilis, chlamydia, gonorrhoea evaluation recommend করে।

B. Scabies — Cause গুলো

  1. মূল parasite:Sarcoptes scabiei var. hominis
    • Female mite skin–এর ভিতরে burrow করে egg দেয়।
    • Immune reaction থেকে itching/rash হয়।
  2. Transmission / ছড়ানোর পথ
    • Prolonged close skin-to-skin contact।
    • Household contact, sexual contact, overcrowding, hostel, prison, refugee camp, nursing home, hospital outbreak–এ common।
    • Adult scabies অনেক সময় sexually acquired হতে পারে।
  3. Incubation
    • প্রথমবার infestation হলে itching শুরু হতে 2–6 সপ্তাহ লাগতে পারে।
    • Reinfestation হলে 24–48 ঘণ্টার মধ্যে itching শুরু হতে পারে।
  4. Crusted scabies risk
    • Immunosuppressed, HIV, elderly, malnourished, steroid user, transplant patient, neurological disability—এ severe crusted scabies হতে পারে। CDC crusted scabies–কে highly transmissible severe infestation হিসেবে উল্লেখ করে।

3. Symptoms / Clinical Features

A. Pubic lice symptoms — point আকারে

  1. Genital itching
    • Pubic area–তে intense itching।
    • রাতে বা warmth–এ বেশি হতে পারে।
  2. Visible lice / nits
    • Pubic hair–এ ছোট crab-like lice দেখা যায়।
    • Hair shaft–এ সাদা/হলুদ nit attached থাকে।
  3. Blue-grey macules / maculae ceruleae
    • Lice bite–এর জায়গায় ছোট bluish spot হতে পারে।
  4. Excoriation / scratch mark
    • বেশি চুলকালে skin break হয়ে যায়।
  5. Dark specks in underwear
    • Lice feces/old blood spot underwear–এ brown/dark dot হিসেবে দেখা যেতে পারে।
  6. Other hairy area involvement
    • Axilla, chest, beard, moustache, eyebrow/eyelash–এ যেতে পারে।
    • Eyelash involvement হলে blepharitis, conjunctivitis, eye irritation হতে পারে।
  7. Secondary bacterial infection
    • Scratching থেকে impetigo, folliculitis, cellulitis হতে পারে। CDC বলছে pubic lice disease transmit করে না, কিন্তু scratching থেকে sores/bacterial infection হতে পারে।

B. Scabies symptoms — point আকারে

  1. Severe nocturnal itching
    • রাতের চুলকানি scabies–এর classic feature।
    • পরিবারের একাধিক সদস্যের একই ধরনের itching থাকলে suspicion বেশি।
  2. Papular rash / pimple-like rash
    • ছোট papule, vesicle, excoriation, eczema-like rash।
  3. Burrow
    • সরু, wavy, grey-white line; mite tunnel।
    • Finger web, wrist, hand border–এ বেশি দেখা যায়।
  4. Common site
    • Finger web
    • Wrist
    • Elbow
    • Axilla
    • Waistline
    • Buttock
    • Penis/scrotum
    • Nipple/breast area
    • Feet/ankle
      CDC common sites হিসেবে finger web, wrist/elbow/knee/axilla folds, penis, nipple, waist, buttocks উল্লেখ করেছে।
  5. Genital nodular scabies
    • Penis/scrotum–এ itchy firm nodule থাকতে পারে।
    • Treatment successful হলেও post-scabetic nodules কিছুদিন থাকতে পারে।
  6. Infant/young child pattern
    • Face, scalp, palm, sole involve হতে পারে।
  7. Crusted scabies
    • Thick crust, scaling, hyperkeratotic plaque।
    • Itching কমও হতে পারে।
    • Highly contagious; specialist management দরকার।

4. Clinical Diagnosis & Investigations

A. Pubic lice diagnosis

  1. Clinical diagnosis
    • Pubic itching + pubic hair–এ lice/nits দেখা।
    • Naked eye, magnifying glass বা dermoscope দিয়ে দেখা যায়। CDC diagnosis–এ itching এবং pubic hair–এ lice/nits দেখা—এগুলোকে clinical basis হিসেবে দিয়েছে।
  2. Specific examination
    • Pubic hair, perianal hair, axilla, chest hair, beard/moustache check।
    • Eyelash/eyebrow involvement থাকলে eye exam।
  3. STI screening
    • HIV Ag/Ab
    • Syphilis: VDRL/RPR + TPHA/TPPA
    • Gonorrhoea/Chlamydia: NAAT urine/urethral/cervical/vaginal/rectal/pharyngeal sample depending exposure
    • Hepatitis B/C risk-based screening
  4. Differential diagnosis
    • Scabies
    • Tinea cruris
    • Folliculitis
    • Candidiasis
    • Contact dermatitis
    • Genital eczema
    • Bedbug/flea bite
    • STI-related genital rash/ulcer

B. Scabies diagnosis

  1. Clinical diagnosis
    • Night itching + typical distribution + household/sexual contact history + burrow।
    • Multiple family member itching = strong clue।
  2. Skin scraping microscopy
    • Burrow/papule থেকে scraping নিয়ে microscope–এ mite, egg, scybala/fecal pellet দেখা।
    • Positive হলে confirmatory, কিন্তু negative হলেও scabies exclude হয় না।
  3. Dermoscopy
    • “Delta-wing jet”/mite head sign দেখা যায়।
    • Experienced operator হলে sensitivity/specificity ভালো। CDC scabies diagnosis–এ burrow, mite, egg/feces identification, microscopy, dermoscopy, adhesive tape test উল্লেখ করেছে।
  4. Adhesive tape test
    • Transparent tape lesion–এর ওপর লাগিয়ে microscope–এ দেখা।
  5. Burrow ink test
    • Ink লাগালে burrow track dark line হিসেবে দেখা যায়।
  6. Biopsy
    • Rarely needed; atypical/crusted/uncertain case।

5. Complications

A. Pubic lice complication

  1. Secondary bacterial infection
    • Scratching থেকে impetigo, cellulitis, folliculitis।
  2. Blepharitis/conjunctivitis
    • Eyelash involvement হলে eye inflammation।
  3. Sleep disturbance ও anxiety
    • Severe itching থেকে insomnia ও embarrassment।
  4. STI co-existence
    • Pubic lice STI transmit করে না, কিন্তু sexual exposure marker; তাই STI screen important।

B. Scabies complication

  1. Impetigo / cellulitis
    • Scratching + skin barrier break → Staphylococcus aureus বা Streptococcus pyogenes infection।
  2. Post-streptococcal glomerulonephritis
    • Streptococcal skin infection–এর পরে kidney complication হতে পারে।
  3. Sepsis
    • Severe secondary infection থেকে bloodstream infection হতে পারে। WHO scabies–এর complications হিসেবে skin sores, septicaemia, heart disease, kidney problems উল্লেখ করেছে।
  4. Crusted scabies outbreak
    • Immunocompromised patient–এ mite burden অনেক বেশি হয়; institution outbreak হতে পারে।
  5. Post-scabetic itch
    • Treatment successful হলেও itching 2–6 সপ্তাহ থাকতে পারে। CDC বলছে successful treatment পরেও rash/pruritus কিছু সময় persist করতে পারে।

6. Treatment Management — Guideline-based

General rule — দুটো রোগেই

  • Patient + sexual partner/close contact একসাথে manage করতে হবে।
  • Pubic lice হলে sexual contact avoid করতে হবে যতক্ষণ patient ও partner treated না হয় এবং bedding/clothing decontamination না হয়। CDC previous month sexual partners treatment বলেছে।
  • Scabies হলে household/close contacts একই দিনে treat না করলে reinfection হবে।
  • Bedding, towel, underwear, clothes hot wash + hot dry করতে হবে; wash সম্ভব না হলে sealed plastic bag–এ কমপক্ষে 72 hours থেকে 1 week রাখা যায়। CDC scabies prevention–এ hot water/hot dryer এবং sealed bag 72 hours to 1 week বলেছে।

A. Pubic lice pharmacological treatment

1. Generic name: Permethrin

Therapeutic category: Pediculicide / Scabicide
Pharmacological class: Synthetic pyrethroid
Purpose: Lice/mite nerve sodium channel disrupt করে paralysis/death করে।
Dose for pubic lice:

  • CDC preferred: Permethrin 1% cream rinse affected pubic hair–এ apply করে 10 মিনিট পরে wash off।
  • Bangladesh–এ MedEx অনুযায়ী Permethrin 5% cream scabies ও crab lice infestation–এর জন্য available/indicated; genital mucosa/eye avoid করে physician direction অনুযায়ী ব্যবহার করা উচিত।
    Repeat: Live lice/nits থাকলে 7–10 দিন পরে repeat।
    Side effects: Burning, stinging, itching, redness, rash, contact dermatitis; eye/mucosal irritation।
    Interaction: Topical absorption খুব কম; major systemic interaction uncommon। অন্য irritant topical drug একই জায়গায় একসাথে না দেওয়া ভালো।
    Contraindication/caution: Pyrethroid allergy, open wound, eye/mucosa exposure avoid।

Bangladesh available brand names — Permethrin 5% w/w cream:
Arotrix, Bepanthin, Delice, Dermanix, Elimate, Ermite, Florixe, Licerin, Lorix, Mecabis, Mithin, Neeper, Noscab, Perclear, Perls, Perma, Permenin, Permethi, Permezen, Permin, Permisol, Perosa, Perscab, Pesimex, Remathrin, Scabex, Scabfre, Scabid, Scameth, Scaper, Scarin, Skilin, Unix, Zunex — mostly 15 g/25 g/30 g tubes depending brand. MedEx lists these as Bangladesh available permethrin 5% brands.

2. Generic name: Ivermectin oral

Therapeutic category: Antiparasitic / Anthelmintic
Pharmacological class: Avermectin macrocyclic lactone
Purpose: Parasite glutamate-gated chloride channel–এ bind করে paralysis/death করে।
Dose for pubic lice alternative: 250 microgram/kg orally, repeat after 7–14 days। CDC ivermectin alternative regimen হিসেবে দিয়েছে এবং food সহ নেওয়ার কথা বলেছে।
Side effects: Nausea, dizziness, headache, diarrhea, rash, pruritus; rare hypotension/neurotoxicity।
Interaction: Warfarin/anticoagulant caution; strong CYP/P-gp interacting drugs caution। CDC ivermectin interaction examples হিসেবে azithromycin, TMP-SMX, cetirizine উল্লেখ করেছে।
Caution: Pregnancy/lactation, severe liver disease, child <15 kg—doctor ছাড়া নয়।

Bangladesh available brand names — Ivermectin tablet:
Ectover 6 mg/12 mg, Imec 6 mg, Imecta 6 mg, Imectin 6 mg/12 mg, Ivactin 6 mg/12 mg, Ivacure 3 mg/6 mg, Ivera 6 mg/12 mg, Ivertin 6 mg, Iverum 6 mg, Ivtin 6 mg/12 mg, Mectin 6 mg/12 mg, Neovera 6 mg/12 mg, Parakil 6 mg, Riovera 6 mg/12 mg, Scabo 3 mg, Univer 6 mg, Veratin 6 mg, Vercov 6 mg, Vermectin 6 mg/12 mg. MedEx lists ivermectin tablets as Bangladesh available brands.

3. Eyelash pubic lice treatment

  • Permethrin/pyrethrin eye–এর কাছে দেওয়া যাবে না।
  • Eyelash involvement হলে ophthalmic occlusive ointment বা petroleum jelly eyelid margin–এ দিনে 2 বার 10 দিন দেওয়া যায়; ophthalmology referral ভালো। CDC eyelash pediculosis–এ ophthalmic ointment/petroleum jelly recommend করেছে।

B. Scabies pharmacological treatment

1. Generic name: Permethrin 5% cream — first line

Therapeutic category: Scabicide
Pharmacological class: Synthetic pyrethroid
Purpose: Sarcoptes scabiei mite kill করার first-line topical drug।
Adult dose:

  • Neck থেকে toe পর্যন্ত পুরো body–তে apply।
  • Finger web, under nail, groin, buttock, genital area, sole—miss করা যাবে না।
  • 8–14 ঘণ্টা রেখে wash off।
  • Repeat after 7 days commonly; CDC regimen 8–14 hours application এবং retreatment symptomatic/live mite হলে consider করে।
    Infant/elderly: Scalp/face may need application, কিন্তু eye/mouth avoid।
    Side effects: Burning, stinging, erythema, itching temporarily increase, rash।
    Interaction: Minimal systemic absorption; other irritating topical medicine একই জায়গায় avoid।
    Caution: Contact dermatitis/pyrethroid allergy।

Bangladesh available brand names:
Same as above — Arotrix, Bepanthin, Delice, Dermanix, Elimate, Ermite, Florixe, Licerin, Lorix, Mecabis, Mithin, Neeper, Noscab, Perclear, Perls, Perma, Permenin, Permethi, Permezen, Permin, Permisol, Perosa, Perscab, Pesimex, Remathrin, Scabex, Scabfre, Scabid, Scameth, Scaper, Scarin, Skilin, Unix, Zunex — Permethrin 5% w/w cream।

2. Generic name: Ivermectin oral — alternative / outbreak / difficult case

Therapeutic category: Antiparasitic
Pharmacological class: Avermectin macrocyclic lactone
Purpose: Oral systemic scabicide; topical application difficult হলে, outbreak/household cluster, resistant/recurrent case, crusted scabies–এ specialist plan–এ useful।
Dose for classic scabies:

  • 200 microgram/kg orally with food
  • Repeat 7–14 days পরে; CDC classic scabies–এ 2 doses 7–14 days apart বলেছে, STI guideline–এ repeat 14 days বলা আছে।
    Example dose calculation:
  • 60 kg patient → 0.2 mg × 60 = 12 mg per dose
  • 70 kg patient → 14 mg per dose; available tablet strength অনুযায়ী physician round করবেন।
    Side effects: Dizziness, nausea, abdominal pain, diarrhea, headache, rash, pruritus; rare neurotoxicity।
    Interaction: Warfarin/anticoagulant caution; CYP3A4/P-gp inhibitor caution; CDC ivermectin interaction examples হিসেবে azithromycin, TMP-SMX, cetirizine উল্লেখ করে।
    Caution: Child <15 kg, pregnancy/lactation, severe hepatic disease—doctor/specialist decision।

Bangladesh available brand names:
Ectover 6/12 mg, Imec 6 mg, Imecta 6 mg, Imectin 6/12 mg, Ivactin 6/12 mg, Ivacure 3/6 mg, Ivera 6/12 mg, Ivertin 6 mg, Iverum 6 mg, Ivtin 6/12 mg, Mectin 6/12 mg, Neovera 6/12 mg, Parakil 6 mg, Riovera 6/12 mg, Scabo 3 mg, Univer 6 mg, Veratin 6 mg, Vercov 6 mg, Vermectin 6/12 mg.

3. Generic name: Benzyl benzoate 25% emulsion/lotion

Therapeutic category: Scabicide / Pediculicide
Pharmacological class: Acaricide / Ectoparasiticide
Purpose: Scabies mite kill করে; permethrin unavailable/contraindicated হলে alternative। European guideline scabies–এ permethrin 5%, oral ivermectin, benzyl benzoate 25% recommended options হিসেবে আছে।
Adult dose:

  • Whole body apply; common regimen: 3 applications at 12-hour interval, তারপর last application–এর 12 ঘণ্টা পরে wash off। Bangladesh medicine source এই regimen উল্লেখ করে।
    Side effects: Burning, stinging, irritant dermatitis, dry skin, eye/mucosal irritation।
    Interaction: Major systemic interaction uncommon; irritant topical products avoid।
    Caution: Broken skin, face/eye/mucosa, pregnancy/neonate—doctor ছাড়া নয়।

Bangladesh available brand names — Benzyl benzoate 25% w/v emulsion:
Ascab, Ascabiol, Benosol, Benzabiol, G-B Benzoate, Scabex, Scabicid, Scabicon, Scabin, Scabisol, Scanil, Viola. MedEx lists these as Bangladesh available benzyl benzoate brands.

4. Generic name: Permethrin + Crotamiton

Therapeutic category: Scabicide + Antipruritic
Pharmacological class: Synthetic pyrethroid + antipruritic/scabicidal agent
Purpose: Scabies mite kill + itching relief।
Strength: Permethrin 5% + Crotamiton 10% lotion
Dose: Product instruction/physician direction অনুযায়ী usually whole body topical application; avoid eye/mucosa।
Side effects: Burning, irritation, erythema, contact dermatitis।
Interaction: Other topical irritants avoid।

Bangladesh available brand names — 5% + 10% lotion:
Arotrix-C, Crotam Plus, Crotamed, Elimate Plus, Lorix Plus, Permisol Max, Perosa Plus, Scabicon Plus, Unix-C. MedEx lists these brands.

5. Generic name: Crotamiton 10%

Therapeutic category: Antipruritic / Scabicide alternative
Pharmacological class: Topical antipruritic, weak scabicidal agent
Purpose: Itching relief; scabies alternative but first-line নয়।
Dose: Usually topical application once daily for 2 nights or physician/product instruction অনুযায়ী; response lower than permethrin।
Side effects: Skin irritation, rash, contact dermatitis।
Interaction: Other irritant topical products avoid।

Bangladesh available brand names:
Crodex cream 10%, Cronix lotion 10%. MedEx lists these crotamiton brands.

Crusted scabies management — specialist only

Crusted scabies হলে simple single permethrin যথেষ্ট নয়। CDC combination treatment হিসেবে topical scabicide repeated schedule + oral ivermectin multiple doses days 1, 2, 8, 9, 15; severe case days 22 ও 29 পর্যন্ত লাগতে পারে বলেছে। Hospital infection-control ও dermatologist/infectious disease specialist দরকার।

7. Prevention / প্রতিরোধ

  1. Pubic lice হলে
    • Treat না হওয়া পর্যন্ত sex বন্ধ।
    • Last 1 month sexual partner inform + treat/check।
    • Underwear, bedsheet, towel hot wash + hot dry।
    • Comb/nit removal helpful, কিন্তু shaving alone cure নয়। CDC বলেছে shaving/waxing lice দূর করে না।
    • STI screen করুন।
  2. Scabies হলে
    • Patient + household/close contacts একই দিনে treat।
    • Clothes, towel, bedding hot wash/hot dry।
    • Wash করা না গেলে sealed plastic bag–এ 72 hours–1 week।
    • Nail short রাখুন; scratching কমান।
    • School/hostel/family outbreak হলে simultaneous treatment plan করুন।
  3. Avoid
    • Same towel/underwear/bed sharing until treated।
    • Random steroid cream ব্যবহার; এতে scabies incognito/secondary infection worsen হতে পারে।
    • Lindane self-use; neurotoxicity risk আছে, CDC lindane not preferred/avoid in pregnancy, breastfeeding, children <10 years, extensive dermatitis বলেছে।

Clinical shortcut

  • Pubic hair–এ visible nit/lice + genital itching = Pubic lice ভাবুন।
  • Night itching + finger web/wrist burrow + family itching = Scabies ভাবুন।
  • Treatment failure-এর common কারণ: ভুল application, partner/contact treat না করা, bedding/clothes decontamination না করা, post-scabetic itch–কে active infection মনে করা।

Overview / Summary

Pubic lice হলো Phthirus pubis দ্বারা pubic/coarse hair infestation; main symptom genital itching ও visible lice/nits। Scabies হলো Sarcoptes scabiei mite skin burrow infestation; main symptom severe nocturnal itching, papular rash, burrow এবং household clustering। Pubic lice–এ permethrin/pyrethrin first-line; scabies–এ permethrin 5% cream first-line। Ivermectin oral alternative, outbreak/difficult case বা selected patient–এ useful, কিন্তু pregnancy, child <15 kg, liver disease–এ caution।

Actionable Plan / Steps

  1. Diagnosis confirm করুন: lesion site examine, lice/nits বা scabies burrow look করুন; uncertain হলে dermoscopy/skin scraping।
  2. Pubic lice হলে: permethrin-based treatment + partner treatment + STI screen।
  3. Scabies হলে: permethrin 5% overnight whole body + repeat 7 days + all household contacts same day।
  4. Linen control: towel, underwear, bedsheet hot wash/hot dry; না পারলে sealed bag ≥72 hours।
  5. Follow-up: 1–2 সপ্তাহ পরে live lice/mite বা new burrow থাকলে retreat/alternative regimen; itching alone 2–6 weeks থাকতে পারে।
  6. Urgent referral: crusted scabies, immunosuppression, infant, pregnancy, eye involvement, secondary bacterial infection, recurrent outbreak।

Reference List

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. Ectoparasitic infections / dermatologic infestations section.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Infectious diseases & skin infestation sections.
  3. Fitzpatrick’s Dermatology, 9th/10th ed. Scabies and pediculosis chapters.
  4. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 9th ed. Ectoparasite infestation chapter.

Guidelines / Official sources

  1. CDC. Sexually Transmitted Infections Treatment Guidelines: Ectoparasitic Infections—Pediculosis pubis and Scabies.
  2. CDC. Treatment of Pubic Lice, 2024.
  3. CDC. Clinical Care of Scabies, 2023/2024.
  4. WHO. Scabies Fact Sheet, 2023.
  5. NICE CKS. Scabies management.

Peer-reviewed journals with DOI

  1. Salavastru CM, et al. European guideline for the management of scabies. J Eur Acad Dermatol Venereol. 2017. DOI: 10.1111/jdv.14351.
  2. Salavastru CM, et al. European guideline for the management of pediculosis pubis. J Eur Acad Dermatol Venereol. 2017. DOI: 10.1111/jdv.14420.
  3. Rosumeck S, Nast A, Dressler C. Ivermectin and permethrin for treating scabies. Cochrane Database Syst Rev. 2018. DOI: 10.1002/14651858.CD012994.
  4. Patel PU, Tan A, Levell NJ. A clinical review and history of pubic lice. Clin Exp Dermatol. 2021. DOI: 10.1111/ced.14666.
  5. Bernigaud C, et al. Combined Oral Ivermectin and 5% Permethrin Cream to Treat Scabies. NEJM. 2026. DOI: 10.1056/NEJMoa2411721.

Md.Rafiqul Islam Lipu.Date:-25-05-2026 Monday Time:-8-59-39 Pm

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