Herpes Zoster: Postherpetic Neuralgia and Other Complications

Focus on Treatment and Prevention
 
 
Adis (Verlag)
  • erschienen am 4. April 2017
  • |
  • XXXIX, 431 Seiten
 
E-Book | PDF mit Wasserzeichen-DRM | Systemvoraussetzungen
978-3-319-44348-5 (ISBN)
 

Representing a state-of-the-art appraisal of this viral infection and its complications, this book comprises contributions from international authorities in infectious diseases, varicella-voster virus infections, and neuropathic pain. Important new information is presented on the role of the virus in terms of vascular risk, notably in heart attack, stroke and granulomatous angiitis (temporal arteritis). Similarly, new information on gastrointestinal involvement, often in the absence of rash and as seen with vasculopathies, is covered. The reader will benefit from new research into the pathology, pathophysiology and treatment of postherpetic neuralgia and its complications, and special attention is paid to prevention through zoster vaccination using the current zoster vaccine, and a novel, broader option that can be used in immunocompromised patients.

This book follows the two editions of the book, Herpes Zoster and Postherpetic Neuralgia, and is divided into sections for the convenience of the reader. A section on herpes zoster includes epidemiology and natural history of the varicella zoster virus, herpes zoster ophthalmicus, neurological complications, the role of varicella zoster virus in giant cell arteritis, concern about increased vascular risk of heart attack and stroke, antiviral therapy, and treatment of skin manifestations. A section on postherpetic neuralgia includes important information on the effect of herpes zoster and postherpetic neuralgia on quality of life, the neuropathology and pathophysiological mechanisms in postherpetic neuralgia, and the new concept of persistent ganglionitis as the cause of postherpetic neuralgia. A comparison is made between facial postherpetic neuralgia and trigeminal neuralgia. There is an extensive section on treatment, including the role of opioids, the general treatment of postherpetic neuralgia, intervention and neurosurgical approaches, and covering guidelines for clinical trial designs in postherpetic neuralgia. A final section addresses the questions of whether aggressive treatment of acute herpes zoster can prevent postherpetic neuralgia and includes a critically important chapter on herpes zoster vaccines.

1st ed. 2017
  • Englisch
  • Cham
  • |
  • Schweiz
Springer International Publishing
  • 59
  • |
  • 50 farbige Tabellen, 24 s/w Abbildungen, 59 farbige Abbildungen
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  • 24 schwarz-weiße und 59 farbige Abbildungen, 50 farbige Tabellen, Bibliographie
  • 12,14 MB
978-3-319-44348-5 (9783319443485)
10.1007/978-3-319-44348-5
weitere Ausgaben werden ermittelt

Dr C. Peter N. Watson has been the chief editor of two essential editions on herpes zoster and postherpetic neuralgia. He is a neurologist in the Department of Medicine, Division of Neurology, University of Toronto, Ontario, Canada. Dr Watson published the first well-conducted trial in postherpetic neuralgia of amitriptyline as an analgesic independent of its effects on depression. Dr Watson enjoys an international reputation for that paper and his other contributions in the same field. These include the two well used volumes Herpes Zoster and Postherpetic Neuralgia, which he both edited and wrote a considerable part of (Watson, 1993; Watson & Gershon, 2001). He wrote the chapter on this topic for Bonica's textbook (3rd edition) and in The Textbook of Pain. His seminal study on amitriptyline was followed by a series of pioneering or definitive trials of other oral medications in postherpetic neuralgia, including maprotiline (1992), nortriptyline (1998), and oxycodone (1998). Dr Watson has received the Canadian Pain Society's highest honour, the Distinguished Career Award, in 2003, and the medal of the Varicella Zoster Research Foundation, in 2007, for his pioneering research on postherpetic neuralgia.

Dr Anne A. Gershon is a Professor of Pediatrics at Columbia University College of Physicians and Surgeons. She is a graduate of Cornell Medical School. Her research over the past 40 years has included epidemiology, diagnosis, immunology, latency, prevention, and treatment of varicella and zoster. Her studies with varicella vaccine were critical for its licensure in the United States. She is continuing to study the safety and efficacy of varicella vaccine in the "vaccine era". She has also focused on HIV infection in children, particularly opportunistic infections. She has received research funding from NIH for the past 40 years. Dr Gershon has served on numerous national and international medical committees. She was President of the Infectious Diseases Society of America (IDSA) in 2009. She has received many professional awards including the Gold medal of the Sabin Vaccine Institute and the Fleming Award of the IDSA. She is the author of over 300 publications and has edited 11 books.

Dr Michael N. Oxman is Professor of Medicine and Pathology at the University of California, San Diego and Sta? Physician in Infectious Diseases at the Veterans A?airs San Diego Healthcare System. He pioneered the use of large double-blind placebo-controlled multi-centre trials to evaluate treatment and prevention of HSV and VZV infections. A student of herpes zoster for 50 years, Dr Oxman led the landmark Shingles Prevention Study, which demonstrated the e?cacy of live attenuated VZV Oka zoster vaccine leading to its licensure and routine use in the US and other countries to prevent herpes zoster and postherpetic neuralgia. Dr Oxman is a recipient of the VZV Research Foundation Lifetime Achievement Award, the Plenary Lectureship honouring Professor Michiaki Takahashi at the 10th Annual Meeting of the Japanese Society of Vaccinology, the Stephen E. Straus Memorial Lectureship in Infectious Diseases at the NIH, the Abraham I. Braude Visiting Professorship at UCSD, and the Department of Veterans A?airs John Blair Barnwell Award for outstanding scienti?c achievements in clinical research.

  • Intro
  • The Patients Speak in Poetry, Art, and Prose
  • My Constant Companion
  • Preface
  • References
  • Preface and Acknowledgments
  • References
  • Patrick D. Wall (1925-2001): An Appreciation
  • References
  • Contents
  • About the Editors
  • Contributors
  • Chapter 1: Introduction
  • 1.1 Fascination
  • 1.2 Frustrations
  • 1.3 Excitement
  • 1.4 Epidemiology, Complications, Pathology
  • 1.5 Vascular Disease
  • 1.6 Three Therapeutic Approaches
  • 1.7 Book Dedications and Caveats
  • References
  • Part I: Varicella (Chickenpox)
  • Chapter 2: Varicella
  • 2.1 Introduction
  • 2.2 Clinical Features of Varicella
  • 2.3 Treatment
  • 2.4 Prevention: Live Attenuated Varicella Vaccine
  • References
  • Part II: Herpes Zoster (Shingles)
  • Chapter 3: Herpes Zoster: A Patient's Perspective
  • 3.1 About My Pain
  • 3.2 Getting Treatment
  • 3.3 Impact on Life, Family, Work, and Finances
  • Commentary
  • References
  • Chapter 4: The Epidemiology and Natural History of Herpes Zoster and Postherpetic Neuralgia
  • 4.1 Introduction
  • 4.2 Herpes Zoster
  • 4.2.1 Incidence of Herpes Zoster in General Population-Based Studies
  • 4.2.2 Morbidity and Mortality of Herpes Zoster
  • 4.2.3 Risk Factors for Herpes Zoster
  • 4.2.3.1 Age
  • 4.2.3.2 Sex
  • 4.2.3.3 Race and Ethnicity
  • 4.2.3.4 Cellular Immune Deficiency
  • 4.2.3.5 Other Risk Factors
  • 4.2.4 Transmission of Varicella-Zoster Virus (VZV) and Herpes Zoster
  • 4.3 Postherpetic Neuralgia
  • 4.3.1 Definitions of PHN
  • 4.3.2 Incidence and Prevalence of PHN
  • 4.3.3 Risk Factors for PHN
  • 4.3.3.1 Greater Age
  • 4.3.3.2 Greater Acute Pain Severity
  • 4.3.3.3 Greater Rash Severity
  • 4.3.3.4 Sensory Dysfunction
  • 4.3.3.5 Immune Response
  • 4.3.3.6 Sex
  • 4.3.3.7 Dermatome
  • 4.3.3.8 Psychosocial Risk Factors
  • 4.4 Conclusions
  • References
  • Chapter 5: Herpes Zoster Ophthalmicus
  • 5.1 Epidemiology
  • 5.2 Acute HZO
  • 5.3 HZO in HIV Patients
  • 5.4 Neurologic Complication
  • 5.5 Management of HZO
  • 5.6 Management of Ocular Complications
  • 5.7 Summary
  • References
  • Chapter 6: Neurological Complications of Herpes Zoster
  • 6.1 Introduction
  • 6.2 Subclinical Spread of Inflammation into the Central Nervous System in Herpes Zoster
  • 6.3 Neurological Complications due to Reactivation of Varicella Zoster Virus Without Rash
  • 6.4 Peripheral Motor Paresis
  • 6.5 Involvement of Cranial Nerves
  • 6.5.1 Ophthalmoplegia
  • 6.5.2 Herpes Zoster Oticus
  • 6.6 The Central Nervous System Complications of Herpes Zoster
  • 6.6.1 Meningitis
  • 6.6.2 Encephalitis
  • 6.6.3 Myelitis
  • 6.6.4 Cerebral Vasculopathy
  • 6.6.5 Diagnosis and Treatment of the Central Nervous System Complications of Herpes Zoster
  • 6.7 Neurological Complications of the Fetus Following Maternal Herpes Zoster
  • 6.8 Summary
  • References
  • Chapter 7: The Role of Varicella Zoster Virus in Giant Cell Arteritis
  • 7.1 Introduction
  • 7.2 Case Reports of GCA and VZV Vasculopathy
  • 7.3 Retrospective Analysis of Archived GCA-Positive and GCA-Negative Temporal Arteries
  • 7.4 Granulomatous Aortitis
  • 7.5 Treatment of GCA
  • 7.6 Conclusion
  • References
  • Chapter 8: Herpes Zoster and Vascular Risk
  • 8.1 Introduction
  • 8.1.1 Complications of Herpes Zoster
  • 8.2 Study Designs
  • 8.3 Epidemiology of Shingles and Stroke
  • 8.4 Epidemiology of Shingles and Other Acute Vascular Complications
  • 8.5 Herpes Zoster Vaccination and Antivirals
  • 8.6 Mechanisms
  • 8.7 What Is Not Known/Future Directions
  • References
  • Chapter 9: Antiviral Therapy and Local Treatment for Herpes Zoster
  • 9.1 Local Treatment for Zoster
  • 9.2 Development of Antivirals
  • 9.3 Newer Antivirals Against VZV
  • 9.4 Impact of Antiviral Therapy on PHN
  • 9.5 Future Directions
  • 9.6 Conclusions
  • References
  • Chapter 10: Dermatologic Manifestations of Herpes Zoster
  • 10.1 Introduction
  • 10.2 Clinical Features
  • 10.3 Complications
  • 10.3.1 Pain
  • 10.3.2 Cutaneous Complications
  • 10.3.2.1 Bacterial Infection
  • 10.3.2.2 Scarring
  • 10.3.2.3 Post-inflammatory Hyperpigmentation
  • 10.3.2.4 Gangrene
  • 10.3.2.5 Wolf's Isotopic Response
  • 10.3.3 Ocular Complications
  • 10.4 Histopathology
  • 10.5 Diagnosis of HZ
  • 10.6 Therapy of HZ
  • 10.6.1 General Measures
  • 10.6.2 Systemic Antibacterial Agents
  • 10.6.3 Glucocorticosteroids
  • 10.6.4 Antiviral Agents
  • 10.7 Conclusion
  • References
  • Part III: Postherpetic Neuralgia: Assessment, Pathology, Pathophysiology
  • Chapter 11: The Effect of Herpes Zoster and Postherpetic Neuralgia on Health-Related Quality of Life, Function, Employment-Related Productivity, and the Cost-Effectiveness of the Vaccine
  • 11.1 Introduction
  • 11.2 Health-Related Quality of Life (HRQoL)
  • 11.2.1 General Concept and Definitions
  • 11.2.2 HRQoL Measures
  • 11.2.3 Generic and Disease-Specific Instruments Commonly Used to Examine the Impact of Herpes Zoster and Postherpetic Neuralgia on HRQoL
  • 11.3 Impact of Herpes Zoster on HRQoL
  • 11.3.1 Impact of Herpes Zoster on HRQoL: Generic Instruments
  • 11.3.2 Impact of Herpes Zoster on HRQoL: Disease-Specific Instrument
  • 11.4 Impact of Postherpetic Neuralgia on HRQoL
  • 11.4.1 Impact of Postherpetic Neuralgia on HRQoL: Generic Instruments
  • 11.4.2 Impact of Postherpetic Neuralgia on HRQoL: Disease-­Specific Instrument
  • 11.5 Impact of Herpes Zoster and Postherpetic Neuralgia on Employment-Related Productivity
  • 11.5.1 General Concept and Measures
  • 11.5.2 Productivity Loss Associated with Herpes Zoster and Postherpetic Neuralgia
  • 11.6 Economic Analyses of the Herpes Zoster Vaccine
  • 11.6.1 General Concept and Definitions
  • 11.6.2 Economic Evaluations of Vaccination against Herpes Zoster
  • 11.7 Conclusion
  • References
  • Chapter 12: The Pathology of Postherpetic Neuralgia and Postherpetic Itch
  • 12.1 Introduction
  • 12.2 Early Pathological Studies
  • 12.3 Head and Campbell [17]
  • 12.4 Later Pathological Studies of Zoster-Affected Ganglia and Central Nervous Tissue
  • 12.5 Pathological Studies of Nerves Extending from Zoster-­Affected Ganglia
  • 12.6 Autopsy Attempts to Discover the Pathologic Signature of PHN
  • 12.7 The Pathology of Facial (Trigeminal) Zoster and PHN
  • 12.8 Skin-Biopsy Studies of Living Patients with Prior Shingles
  • 12.9 Bilateral Neuropathology after Unilateral Shingles
  • 12.10 The Pathology of Postherpetic Itch (PHI) and Associated Self-Injury
  • 12.11 Summary
  • References
  • Chapter 13: Neural Basis of Pain in Herpes Zoster and Postherpetic Neuralgia: The Ectopic Pacemaker Hypothesis
  • 13.1 Introduction
  • 13.2 Spontaneous and Evoked Neuropathic Pain
  • 13.3 Spontaneous Pain in HZ and PHN
  • 13.3.1 VZV Causes Varicella, HZ, and PHN
  • 13.3.2 Do the Impulses That Cause Spontaneous Pain in HZ and PHN Originate in the Skin?
  • 13.3.3 Ectopic Pacemakers in the Skin
  • 13.3.4 "Deafferentation" and the Spinal Cord as a Pain Driver in HZ and PHN
  • 13.4 Hypersensibility to Applied Stimuli and Tactile Allodynia
  • 13.4.1 Tactile Allodynia: Irritable Nociceptors or Central Sensitization?
  • 13.4.2 The Significance of Dermatomal Overlap
  • 13.5 Summary and Perspective
  • References
  • Chapter 14: Persistent VZV Ganglionitis May Be the Cause of Postherpetic Neuralgia
  • 14.1 Zoster and Postherpetic Neuralgia
  • 14.2 Postherpetic Neuralgia, Preherpetic Neuralgia, and Zoster Sine Herpete
  • 14.3 The Possible Viral Cause of Postherpetic Neuralgia (PHN)
  • 14.4 Perspective on Antiviral Therapy for Postherpetic Neuralgia (PHN)
  • 14.5 Conclusion
  • Editorial Comment
  • References
  • Chapter 15: A Comparison of Clinical Features and Mechanisms of Trigeminal Postherpetic Neuralgia and Trigeminal Neuralgia
  • 15.1 Introduction
  • 15.2 Case Studies
  • 15.3 Historical
  • 15.4 Epidemiology, Incidence, and Natural History of TN and TPHN
  • 15.4.1 Clinical Features
  • 15.4.2 Pathology
  • 15.5 Treatment
  • 15.5.1 Medical
  • 15.5.2 Surgery
  • 15.6 Pathophysiology: TN and TPHN Mechanisms
  • 15.6.1 Spinal Neuropathic Pain Models and Mechanisms
  • 15.6.2 Trigeminal Somatosensory System: Normal Features and Neuropathic Processes
  • 15.6.2.1 Normal Features
  • Trigeminal Primary Afferent Mechanisms
  • Trigeminal Brainstem Mechanisms
  • Thalamocortical Mechanisms
  • Modulation of CNS Nociceptive Processes
  • 15.6.2.2 Trigeminal Neuropathic Pain Models and Mechanisms
  • Peripheral Trigeminal Neuropathic Pain Processes
  • Central Trigeminal Neuropathic Pain Processes
  • Brainstem Processes
  • Thalamocortical Processes
  • 15.6.2.3 TN Models and Mechanisms
  • 15.6.2.4 TPHN Models and Mechanisms
  • 15.7 Final Perspectives, Future Directions, and Concluding Remarks
  • References
  • Part IV: Postherpetic Neuralgia: Treatment
  • Chapter 16: Treatment of Postherpetic Neuralgia: Subtypes and a Mechanism-Based Treatment
  • 16.1 Introduction
  • 16.2 Where Do We Stand Today?
  • 16.3 Classification of Patients Based on Sensory Abnormalities
  • 16.4 Potential Mechanisms Operating in Different Subgroups
  • 16.4.1 Subgroup 1
  • 16.4.2 Subgroup 2
  • 16.4.3 Subgroup 3
  • 16.5 Treatment Studies Using Mechanism-Based Classification
  • 16.6 Limitations of the Approach
  • 16.7 Future Implications for Therapy and Clinical Trials
  • 16.8 Conclusions
  • References
  • Chapter 17: Interventional Approaches to Postherpetic Neuralgia
  • 17.1 Introduction
  • 17.2 General Considerations
  • 17.3 Nerve Blocks
  • 17.3.1 Timing of Interventions
  • 17.3.2 Acute Pain Control
  • 17.3.3 Preemptive Nerve Blocks to Prevent Postherpetic Neuralgia
  • 17.3.4 Treatment of Postherpetic Neuralgia with Nerve Blocks
  • 17.4 Neuromodulation
  • 17.4.1 Spinal Cord Stimulation
  • 17.4.2 Intrathecal Therapy
  • 17.4.3 Radiofrequency Procedures
  • 17.5 Conclusions
  • References
  • Chapter 18: Treatment of Postherpetic Neuralgia: The Role of Opioids
  • 18.1 Introduction
  • 18.2 Adaptations to Chronic Opioid Use
  • 18.2.1 Tolerance
  • 18.2.2 Physical Dependence
  • 18.2.3 Tolerance and Dependence Cannot Be Separated
  • 18.2.4 What Is Addiction?
  • 18.2.5 Implications
  • 18.3 Opioid Harms
  • 18.4 Which Patients Are Suitable Candidates?
  • 18.4.1 Prodromal Phase
  • 18.4.2 Acute Phase
  • 18.4.3 Subacute Phase
  • 18.4.4 Postherpetic Neuralgia (PHN)
  • 18.5 Which Opioid, Which Dose?
  • 18.5.1 "Mild" Opioids
  • 18.5.2 Tapentadol
  • 18.5.3 Pure Mu Opioid Agonists
  • 18.5.4 Mixed Agonist Antagonists
  • 18.5.5 Dose
  • 18.5.6 Titrating to Effect: A Bad Idea When Pain Is Chronic
  • 18.6 Sensible Precautions
  • 18.6.1 At the Start of Opioid Therapy/Acute Pain
  • 18.6.2 When Opioid Is Selected as Chronic Pain Treatment
  • 18.6.2.1 The Care Agreement
  • 18.6.2.2 Urine Toxicology
  • 18.6.2.3 Prescription Monitoring
  • 18.7 Conclusions and Controversies
  • 18.7.1 A Palliative Care Construct
  • 18.7.2 What Is Different About Herpes Zoster Pain
  • 18.8 Commentary
  • References
  • Chapter 19: Postherpetic Neuralgia: Difficult to Treat, Easier to Prevent
  • 19.1 Introduction
  • 19.2 Clinical Features (Fig. 19.7)
  • 19.2.1 Pain Assessment
  • 19.2.2 Physical Examination
  • 19.2.3 Putative Pain Mechanisms Based on Pathology, Clinical Features and Pharmacodynamics, and Implications
  • 19.3 Management Options
  • 19.4 How Effective Are Pharmacological Agents for PHN in Clinical Practice?
  • 19.5 Practical Guidelines for the Prevention and Treatment of Postherpetic Neuralgia
  • 19.5.1 The Prevention of PHN by Treatment of HZ (Also Chap. 23)
  • 19.5.2 Prevention by Vaccination
  • 19.5.3 A Practical Approach to the Treatment of Postherpetic Neuralgia
  • 19.6 Summary
  • References
  • Chapter 20: Postherpetic Neuralgia: Are There Neurosurgical Options?
  • 20.1 Introduction
  • 20.1.1 Definitions
  • 20.1.2 Epidemiology and Natural History (Chap. 4)
  • 20.1.3 Pathology and Putative Pain Mechanisms
  • 20.1.4 Clinical Features (Figs 20.5 and 20.6)
  • 20.1.5 Outcomes: Management Options (Book Sects. IV and V)
  • 20.1.6 Neurosurgical Approaches
  • 20.2 Summary
  • References
  • Chapter 21: Designing Randomized Controlled Trials of Oral Analgesics for Chronic Postherpetic Neuralgia
  • 21.1 Introduction
  • 21.2 Elements of Clinical Trials
  • 21.2.1 Selectionof Trial Participants
  • 21.2.2 Study Treatment, Placebo, and Comparator(s)
  • 21.2.3 Trial Designs
  • 21.2.4 Outcome Measures
  • 21.2.5 Trial Duration and Sample Size
  • 21.3 Current Challenges and Future Directions
  • 21.4 Conclusion
  • References
  • Part V: The Prevention of Herpes Zoster and Postherpetic Neuralgia
  • Chapter 22: The Importance of Zoster Prevention Vaccines
  • 22.1 Clinical
  • 22.2 Pathological
  • 22.3 Therapeutic
  • 22.4 Preventative
  • 22.5 Epidemiological
  • 22.6 Conclusion
  • References
  • Chapter 23: Aggressive Noninvasive Treatment of Acute Herpes Zoster for the Prevention of Postherpetic Neuralgia
  • 23.1 Introduction
  • 23.2 Systemic Antiviral Therapy
  • 23.3 Oral Glucocorticoids
  • 23.4 Opioid and Non-opioid Analgesic Agents
  • 23.5 Other Agents
  • 23.6 Summary and Recommendations
  • References
  • Chapter 24: Herpes Zoster Vaccines
  • 24.1 Introduction
  • 24.1.1 The Nature of Herpes Zoster
  • 24.1.2 Complications
  • 24.1.3 VZV Latency
  • 24.1.4 Reactivation of Latent VZV
  • 24.2 The Central Role of Immunity to VZV in the Pathogenesis of Herpes Zoster
  • 24.3 Live Attenuated Oka VZV Vaccine
  • 24.4 The Challenge of Vaccinating Against Herpes Zoster
  • 24.5 The Shingles Prevention Study (SPS)
  • 24.5.1 Description of the Study
  • 24.5.2 Evaluation of Suspected Cases of Herpes Zoster
  • 24.5.3 Diagnosis of Herpes Zoster
  • 24.5.4 Efficacy End Points
  • 24.5.5 Results: Vaccine Efficacy
  • 24.5.6 Results: Vaccine Efficacy for Zoster-Related Interference with Functional Status and Quality of Life
  • 24.5.7 Safety of Zoster Vaccine
  • 24.5.8 Immune Responses to Zoster Vaccine
  • 24.6 Persistence of Zoster Vaccine Efficacy
  • 24.7 Immune Response to a Booster Dose of Zoster Vaccine
  • 24.7.1 Intramuscular Versus Subcutaneous Administration
  • 24.8 Efficacy and Safety of Zoster Vaccine in Persons 50-59 Years of Age
  • 24.9 Other Oka Zoster Vaccines
  • 24.9.1 Refrigerator-Stable Zoster Vaccine
  • 24.9.2 Heat-Inactivated Zoster Vaccine
  • 24.10 Safety and Effectiveness of Live Attenuated Zoster Vaccine
  • 24.10.1 Safety of Zoster Vaccine in the General Population
  • 24.10.2 Zoster Vaccine Effectiveness in the General Population
  • 24.10.3 Additional Effectiveness Studies
  • 24.10.4 Safety and Effectiveness of Zoster Vaccine in Persons with Comorbidities
  • 24.10.5 Safety and Immunogenicity of Live Attenuated Oka Vaccine in Persons with HIV Infection
  • 24.10.6 Safety and Immunogenicity of Zoster Vaccine in Immunocompromised Patients
  • 24.11 Concomitant Administration
  • 24.12 New Improved Vaccines
  • 24.13 Barriers to Uptake of Zoster Vaccine
  • 24.14 Future Directions
  • References
  • Chapter 25: Conclusion: "All Roads Lead to Rome"
  • Three Drawings by Susan Telling
  • Index
DNB DDC Sachgruppen
Dewey Decimal Classfication (DDC)

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