Zusammenfassung
Der Verlauf der HIV-Infektion ist durch eine progrediente Immundefizienz und ein gesteigertes Risiko für die Entwicklung opportunistischer Infektionen und Neoplasien gekennzeichnet. Infektionen der Lunge spielen dabei eine besondere Rolle, da die Atemwege ständigem Kontakt mit Mikroorganismen aus der Atemluft ausgesetzt sind. Neben dem Spektrum der Erreger ambulant erworbener Pneumonien treten mit zunehmender Immunschwäche auch Infektionen durch Mikroorganismen auf, die von Defekten der zellulären Immunabwehr profitieren. Hierzu gehören u.a. Infektionen mit Pneumocystis jirovecii, nicht-tuberkulösen Mykobakterien und viralen Erregern. Im Gegensatz dazu tritt die Tuberkulose auch schon in frühen Stadien der HIV-Infektion gehäuft auf. Als Folge der HIV-Pandemie ist die Inzidenz der Tuberkulose daher in vielen Ländern wieder stark angestiegen. In den vergangenen Jahren ist es aber durch den Einsatz einer kombinierten antiretroviralen Therapie (ART) in den industrialisierten Ländern gelungen, die HIV-assoziierte Morbidität und Mortalität drastisch zu senken. Als Folge der Immunrekonstitution unter ART ist damit auch die Inzidenz pulmonaler Koinfektionen in Ländern, in denen diese Therapien verfügbar sind, deutlich zurückgegangen.
Abstract
HIV-infection is characterized by a progressive immunodeficiency that predisposes affected persons to opportunistic infections and neoplasias. Pulmonary co-infections play a key role in HIV-infection as the airways are constantly exposed to aerosolized microorganisms during ventilation. In addition to the spectrum of microorganisms that are responsible for the development of community acquired pneumonia in immunocompetent hosts, persons with HIV-infection are vulnerable to infections with organisms that profit from the progressive cellular immune defects. Examples are infections with Pneumocystis jirovecii, non-tuberculous mycobacteria and viral pathogens. In contrast, tuberculosis can occur in all stages of HIV-infection. Following the HIV-pandemic, the incidence of tuberculosis has increased again in many areas of the world. The advent of antiretroviral therapies (ART) in recent years had resulted in a dramatic decrease of HIV-related morbidity and mortality in industrialized countries. As a result of the reconstitution of the immune-system under ARTs the incidence of pulmonary co-infections has also declined substantially in persons living with HIV in countries where these therapies are available.
Literatur
-
1
Update: AIDS-United States 2000.
MMWR.
2002;
51
592-(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5127a2.htm)
-
2
Robert Koch Institut .
HIV-Infektionen und AIDS Erkrankungen in Deutschland (Stand 31.12.2003).
Epidemiol Bull.
2004;
Sonderausgabe A
-
3
Delta: a randomised double-blind controlled trial comparing combinations of zidovudine plus didanosine or zalcitabine with zidovudine alone in HIV-infected individuals. Delta Coordinating Committee.
Lancet.
1996;
348
283-291
-
4
Hammer S M, Katzenstein D A, Hughes M D. et al .
A trial comparing nucleoside monotherapy with combination therapy in HIV-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter. AIDS Clinical Trials Group Study 175 Study Team.
N Engl J Med.
1996;
335
1081-1090
-
5
Cameron D W, Heath-Chiozzi M, Danner S. et al .
Randomised placebo-controlled trial of ritonavir in advanced HIV-1 disease. The Advanced HIV Disease Ritonavir Study Group.
Lancet.
1998;
351
543-549
-
6
Palella Jr F J, Delaney K M, Moorman A C. et al .
Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection.
N Engl J Med.
1998;
338
853-860
-
7
Mocroft A, Ruiz L, Reiss P. et al .
Virological rebound after suppression on highly active antiretroviral therapy.
AIDS.
2003;
17
1741-1751
-
8
Mocroft A, Katlama C, Johnson A M. et al .
AIDS across Europe, 1994 - 1998: the EuroSIDA study.
Lancet.
2000;
356
291-296
-
9
Mellors J W, Munoz A, Giorgi J V. et al .
Plasma viral load and CD4+-lymphocytes as prognostic markers of HIV-1-infection.
Ann Intern Med.
1997;
126
946-954
-
10
Lyles R H, Munoz A, Yamashita T E. et al .
Natural history of human immunodeficiency virus type 1 viremia after seroconversion and proximal to AIDS in a large cohort of homosexual men. Multicenter AIDS Cohort Study.
J Infect Dis.
2000;
181
872-880
-
11
Yeni P G, Hammer S M, Carpenter C C. et al .
Antiretroviral treatment for adult HIV infection in 2002: updated recommendations of the International AIDS Society-USA Panel.
JAMA.
2002;
288
222-235
-
12
BHIVA Writing Committee; BHIVA Executive Committee .
British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy.
HIV Med.
2001;
2
276-313
-
13
Kahn J O, Walker B D.
Acute human immunodeficiency virus type-1-infection.
N Engl J Med.
1998;
339
33-39
-
14
Rosenberg E S, Altfeld M, Poon S H. et al .
Immune control of HIV-1 after early treatment of acute infection.
Nature.
2000;
407
523-526
-
15 Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents; http://aidsinfo.nih.gov/guidelines. 2003
-
16
Powderly W G, Saag M S, Chapman S. et al .
Predictors of optimal virological response to potent antiretroviral therapy.
AIDS.
1999;
13
1873-1880
-
17
Mocroft A, Youle M, Moore A. et al .
Reasons for modification and discontinuation of antiretrovirals: results from a single treatment centre.
AIDS.
2001;
15
185-194
-
18
Schaaf B, Aries S P, Kramme E. et al .
Acute renal failure associated with tenofovir treatment in a patient with acquired immunodeficiency syndrome.
Clin Infect Dis.
2003;
37
e41-43
-
19
Friis-Moller N, Sabin C A, Weber R. et al .
Combination antiretroviral therapy and the risk of myocardial infarction.
N Engl J Med.
2003;
349
1993-2003
-
20
Petropoulos C J, Parkin N T, Limoli K L. et al .
A novel phenotypic drug susceptibility assay for human immunodeficiency virus type 1.
Antimicrob Agents Chemother.
2000;
44
920-928
-
21
Vanhove G F, Schapiro J M, Winters M A. et al .
Patient compliance and drug failure in protease inhibitor monotherapy.
JAMA.
1996;
276
1955-1956
-
22
Paterson D L, Swindells S, Mohr J. et al .
Adherence to protease inhibitor therapy and outcomes in patients with HIV-infection.
Ann Intern Med.
2000;
133
21-30
-
23
Baxter J D, Merigan T C, Wentworth D N. et al .
Both baseline HIV-1 drug resistance and antiretroviral drug levels are associated with short-term virologic responses to salvage therapy.
AIDS.
2002;
16
1131-1138
-
24
Phillips A N, Miller V, Sabin C. et al .
Durability of HIV-1 viral suppression over 3.3 years with multi-drug antiretroviral therapy in previously drug-naive individuals.
AIDS.
2001;
15
2379-2384
-
25
Mezzaroma I, Carlesimo M, Pinter E. et al .
Clinical and immunologic response without decrease in virus load in patients with AIDS after 24 months of highly active antiretroviral therapy.
Clin Infect Dis.
1999;
29
1423-1430
-
26
Mocroft A, Ledergerber B, Katlama C. et al .
Decline in the AIDS and death rates in the EuroSIDA study: an observational study.
Lancet.
2003;
362
22-29
-
27
Stoll M, Claes C, Schulte E. et al .
Direct costs for the treatment of HIV-infection in a German cohort after the introduction of HAART.
Eur J Med Res.
2002;
7
463-471
-
28
Sendi P P, Bucher H C, Harr T. et al .
Cost effectiveness of highly active antiretroviral therapy in HIV-infected patients. Swiss HIV Cohort Study.
AIDS.
1999;
13
1115-1122
-
29
Ferrer E, Podzamczer D.
Management of opportunistic infections in the era of highly active antiretroviral therapy.
AIDS Rev.
2000;
2
252-262
-
30
Brodt H, Kamps B, Gute P. et al .
Changing incidence of AIDS-defining illnesses in the era of antiretroviral combination therapy.
AIDS.
1997;
11
1731-1738
-
31
Mayaud C, Cadranel J.
AIDS and the lung in a changing world.
Thorax.
2001;
56
423-426
-
32
Wallace J M, Hansen N I, Lavange L. et al .
The Pulmonary Complications of HIV-Infection Study Group.
Am J Respir Crit Care Med.
1997;
XI55
72-80
-
33 Robert Koch-Institut .Bericht des Aids-Zentrums im RKI über aktuelle epidemiologische Daten, Quartalsbericht IV/98.
-
34
Sullivan Feldman C, Glatthaar M, Morar R. et al .
Bacteremic pneumococcal pneumonia in HIV-Seropositive and HIV-Seronegative Adults.
CHEST.
1999;
116
107-114
-
35
Feldman C, Glatthaar M, Morar R. et al .
Bacteremic Pneumococcal Pneumonia in HIV-Seropositive and HIV-Seronegative Adults.
CHEST.
1999;
116
107-114
-
36
Baughman R P, Dohn M, Frame P.
The Continuing Utility of Bronchoalveolar Lavage to Diagnose Opportunistic Infection in AIDS-Patients.
Am J Med.
1994;
97
515-525
-
37
Koch A, Kothe H, Braun J. et al .
Inzidenz bakterieller Pneumonien bei HIV-positiven Patienten unter Co-trimoxazol oder Pentamidin.
Pneumologie.
1998;
52
614-621
-
38
Miller R F, Foley N M, Kessel D. et al .
Community acquired lobar pneumonia in patients with HIV-infection and AIDS.
Thorax.
1994;
49
367-368
-
39
DeGarcia J, Miravitlles M, Mayordomo C. et al .
Empiric Treatments Impair the Diagnostic Yield of BAL in HIV-Positive Patients.
CHEST.
1997;
111
1180-1186
-
40
Caiffa W T, Graham N MH, Vlahov D.
Bacterial pneumonia in adult populations with Human Immundeficiency Virus infection.
Am J Epidemiol.
1993;
138
909-922
-
41
Saag M S, Graybill R J, Larsen R A. et al .
Practice guidelines for the management of cryptococcal disease.
Clin Infect Dis.
2000;
30
710-718
-
42
Schaberg T, Dalhoff K, Ewig S. et al .
Empfehlungen zur Therapie der ambulant erworbenen Pneumonie.
Pneumologie.
1998;
52
450-462
-
43
Dalhoff K, Ewig S, Höffken G. et al .
Empfehlungen zur Diagnostik, Therapie und Prävention von Pneumonien bei erworbenem Immundefizit.
Pneumologie.
2002;
56
807-831
-
44 UNAIDS report for 2003: most deaths and new infections ever; some good news. AIDS Treat News 2003 3
-
45
Colebunders R, Lambert M L.
Management of co-infection with HIV and TB.
Bmj.
2002;
324
802-803
-
46
Robert Koch-Institut .
Tuberkulose im Jahr 2002.
Epidemiologisches Bulletin.
2003;
50
419-420
-
47
Robert Koch-Institut .
HIV-Infektionen und AIDS Erkrankungen in Deutschland. Aktuelle Epidemiologische Daten (Stand 30.06.2003).
Epidemiologisches Bulletin.
2003;
Sonderausgabe B
1-16
-
48
Bloom B R, Murray C J.
Tuberculosis: commentary on a reemergent killer.
Science.
1992;
257
1055-1064
-
49
Raviglione M C, Harries A D, Msiska R. et al .
Tuberculosis and HIV: current status in Africa.
Aids.
1997;
11 Suppl B
S115-123
-
50
Havlir D V, Barnes P F.
Tuberculosis in patients with human immunodeficiency virus infection.
N Engl J Med.
1999;
340
367-373
-
51
Toossi Z.
Virological and immunological impact of tuberculosis on human immunodeficiency virus type-1-disease.
J Infect Dis.
2003;
188
1146-1155
-
52
Ackah A N, Coulibaly D, Digbeu H. et al .
Response to treatment, mortality, and CD4-lymphocyte counts in HIV-infected persons with tuberculosis in Abidjan, Cote d’Ivoire.
Lancet.
1995;
345
607-610
-
53
Wood R, Maartens G, Lombard C J.
Risk factors for developing tuberculosis in HIV-1-infected adults from communities with a low or very high incidence of tuberculosis.
J Acquir Immune Defic Syndr.
2000;
23
75-80
-
54
Toossi Z, Mayanja-Kizza H, Hirsch C S. et al .
Impact of tuberculosis (TB) on HIV-1-activity in dually infected patients.
Clin Exp Immunol.
2001;
123
233-238
-
55
Mellors J W, Rinaldo Jr C R, Gupta P. et al .
Prognosis in HIV-1-infection predicted by the quantity of virus in plasma.
Science.
1996;
272
1167-1170
-
56
Toossi Z, Johnson J L, Kanost R A. et al .
Increased replication of HIV-1 at sites of Mycobacterium tuberculosis infection: potential mechanisms of viral activation.
J Acquir Immune Defic Syndr.
2001;
28
1-8
-
57
Toossi Z, Nicolacakis K, Xia L. et al .
Activation of latent HIV-1 by Mycobacterium tuberculosis and its purified protein derivative in alveolar macrophages from HIV-infected individuals in vitro.
J Acquir Immune Defic Syndr Hum Retrovirol.
1997;
15
325-331
-
58
Mayanja-Kizza H, Wajja A, Wu M. et al .
Activation of beta-chemokines and CCR5 in persons infected with human immunodeficiency virus type 1 and tuberculosis.
J Infect Dis.
2001;
183
1801-1804
-
59
Nambuya A, Sewankambo N, Mugerwa J. et al .
Tuberculous lymphadenitis associated with human immunodeficiency virus (HIV) in Uganda.
J Clin Pathol.
1988;
41
93-96
-
60
Elliott A M, Halwiindi B, Hayes R J. et al .
The impact of human immunodeficiency virus on presentation and diagnosis of tuberculosis in a cohort study in Zambia.
J Trop Med Hyg.
1993;
96
1-11
-
61 Harries A D, Maher D. TB/HIV: A clinical Manual. Geneva: WHO 1996: 135
-
62
Jasmer R M, Nahid P, Hopewell P C.
Clinical practice. Latent tuberculosis infection.
N Engl J Med.
2002;
347
1860-1866
-
63
Fisk T L, Hon H M, Lennox J L. et al .
Detection of latent tuberculosis among HIV-infected patients after initiation of highly active antiretroviral therapy.
Aids.
2003;
17
1102-1104
-
64
Whalen C, Horsburgh Jr C R, Hom D. et al .
Site of disease and opportunistic infection predict survival in HIV-associated tuberculosis.
Aids.
1997;
11
455-460
-
65
Perlman D C, el-Sadr W M, Nelson E T. et al .
Variation of chest radiographic patterns in pulmonary tuberculosis by degree of human immunodeficiency virus-related immunosuppression. The Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). The AIDS Clinical Trials Group (ACTG).
Clin Infect Dis.
1997;
25
242-246
-
66
Espinal M A, Perez E N, Baez J. et al .
Infectiousness of Mycobacterium tuberculosis in HIV-1-infected patients with tuberculosis: a prospective study.
Lancet.
2000;
355
275-280
-
67
Cruciani M, Malena M, Bosco O. et al .
The impact of human immunodeficiency virus type 1 on infectiousness of tuberculosis: a meta-analysis.
Clin Infect Dis.
2001;
33
1922-1930
-
68
CDC .
Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations. Centers for Disease Control and Prevention.
MMWR Recomm Rep.
1998;
47
1-58
-
69
Barnes P F.
Rapid diagnostic tests for tuberculosis: progress but no gold standard.
Am J Respir Crit Care Med.
1997;
155
1497-1498
-
70
Conde M B, Soares S L, Mello F C. et al .
Comparison of sputum induction with fiberoptic bronchoscopy in the diagnosis of tuberculosis: experience at an acquired immune deficiency syndrome reference center in Rio de Janeiro, Brazil.
Am J Respir Crit Care Med.
2000;
162
2238-2240
-
71
Narayanswami K, Salzman S H.
Bronchoscopy in the human immunodeficiency virusinfected patient.
Semin Respir Infect.
2003;
18
80-86
-
72
Chaisson R E, Clermont H C, Holt E A. et al .
Six-month supervised intermittent tubercuslosis therapy in Haitan patients with and without HIV-infection.
Am J Respir Crit Care Med.
1996;
154
1034-1038
-
73
Hung C C, Chen M Y, Hsiao C F. et al .
Improved outcomes of HIV-1-infected abdults with tuberculosis in the era of highly active antiretroviral therapy.
AIDS.
2003;
17
2615-2622
-
74
Burman W J, Jones B E.
Treatment of HIV-related tuberculosis in the era of effective antiretroviral therapy.
Am J Respir Crit Care Med.
2001;
164
7-12
-
75
Narita M, Ashkin D, Hollender E S. et al .
Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS.
Am J Respir Crit Care Med.
1998;
158
157-161
-
76 Updated Guidelines for the Use of Rifamycins for the Treatment of Tuberculosis Among HIV-Infected Patients Taking Protease Inhibitors or Nonnucleoside Reverse Transcriptase Inhibitors .Division of Tuberculosis Elimination, CDC, http:/www.cdc.gov/nchstp/tb/TB HIV Drugs/TOC.htm. 2004
-
77 Schieferstein C, Lange C. Tuberkulose. In: Hoffmann C, Kamps BS (eds.). HIV.NET 2004. Steinhäuser Verlag 2004: 363-373
-
78
CDC .
Treatment of tuberculosis.
MMWR Recomm Rep.
2003;
52
1-77
-
79
Dean G L, Edwards S G, Ives N J. et al .
Treatment of tuberculosis in HIV-infected persons in the era of highly active antiretroviral therapy.
AIDS.
2002;
16
75-83
-
80
Schaberg T, Forssbohm M, Hauer B. et al .
[Guidelines for drug treatment of tuberculosis in adults and childhood].
Pneumologie.
2001;
55
494-511
-
81
Pozniak A.
Multidrug-resistant tuberculosis and HIV-infection.
Ann N Y Acad Sci.
2001;
953
192-198
-
82
Bucher H C, Griffith L E, Guyatt G H. et al .
Isoniazid prophylaxis for tuberculosis in HIV-infection: a meta-analysis of randomized controlled trials.
Aids.
1999;
13
501-507
-
83
Churchyard G J, Fielding K, Charalambous S. et al .
Efficacy of secondary isoniazid preventive therapy among HIV-infected Southern Africans; time to change policy?.
AIDS.
2003;
17
2063-2070
-
84
CDC .
Targeted tuberculin testing and treatment of latent tuberculosis infection. American Thoracic Society.
MMWR Recomm Rep.
2000;
49
1-51
-
85
ATS/COC .
Update: adverse event data and revised American Thoracic Society/CDC recommendations against the use of rifampin and pyrazinamide for treatment of latent tuberculosis infection-United States, 2003.
MMWR Morb Mortal Wkly Rep.
2003;
52
735-739
-
86
Nightingale S D, Byrd L T, Southern P M. et al .
Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients.
J Infect Dis.
1992;
165 (6)
1082-1085
-
87
Lange C G, Woolley I J, Brodt R H.
Disseminated Mycobacterium avium-intracellulare complex (MAC) infection in the era of effective antiretoviral therapy.
Drugs.
2004;
64
679-692
-
88
Jones D, Havlir D V.
Nontuberculous mycobacteria in the HIV-infected patient.
Clin Chest Med.
2002;
23
665-674
-
89
Brown-Elliott B A, Griffith D E, Wallace R J.
Newly described or emerging human species of nontuberculous mycobacteria.
Infect Dis Clin North Am.
2002;
16 (1)
187-220
-
90
ATS .
Scientific assembly on microbiology, tuberculosis and pulmonary infections, American Thoracic Society. Diagnosis and treatment of disease caused by nontuberculous mycobacteria.
Am J Respir Crit Care Med.
1997;
156 (2 - 2)
1-25
-
91
Metersky M L, Colt H G, Olson L K. et al .
AIDS-Related spontaneous pneumothorax, risk factors and treatment.
CHEST.
1995;
108
946-951
-
92
Cadranel J, Gillet-Juvin K, Antoine M. et al .
Site-directed bronchoalveolar lavage and transbronchial biopsy in HIV-infected patients with pneumonia.
Am J Respir Crit Care Med.
1995;
152
1103-1106
-
93
Jules-Elysee K M, Stover D E, Zaman M B.
Aerosolized pentamidine: Effect on diagnosis and presentation of penumocystis carinii pneumonia.
Ann Intern Med.
1990;
112
750-757
-
94
Turner D, Schwartz Y, Yust I.
Induced sputum for diagnosing Pneumocystis carinii pneumonia in HIV-patients: new data, new issues.
Eur Respir J.
2003;
21
204-208
-
95
Sattler F R, Cowan R, Nielsen D M. et al .
Trimethoprim-Sulfamethoxazole compared with pentamidine for treatment of pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome.
Ann Intern Med.
1988;
109
280-287
-
96
Safrin S, Lee B L, Sande M A.
Adjunctive folinic acid with trimethoprim-sulfamethoxazole for pneumocystis carinii pneumonia in AIDS-patients is associated with an increased risk of therapeutic failure and death.
J Infect Dis.
1994;
170
912-917
-
97
Conte J E, Chernoff D, Feigal D W. et al .
Inhaled pentamidine for treating pneumocystis carinii pneumonia in AIDS.
Ann Intern Med.
1990;
113
203-209
-
98
Medina I, Mills J, Leoung G. et al .
Oral therapy for pneumocystis carinii pneumonia in the acquired immonodeficiency syndrome.
N Engl J Med.
1990;
323
776-782
-
99
Bozzette S A, Sattler F R, Chiu J. et al .
A controlled trial of early adjunctive treatment with corticosteroids für Pneumocyctis carinii pneumonia in the acquired immunodeficiency syndrome.
N Engl J Med.
1990;
323
1451-1457
-
100
Schneider M ME, Hoepelman A IM, Eeftinck Schattenkerk J KM. et al .
A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection.
N Engl J Med.
1992;
327
1836-1840
-
101
Bozette S A, Finkelstein D M, Spector S A.
A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection.
N Engl J Med.
1995;
332
693-699
-
102 Hill H E, Wallace M, Kennedy C. Prophylaxis of pneumocystis carinii pneumonia with dapsone; an evaluation of toxicity and cross-reactivity with trimethoprim-sulfamethoxazole. International Conference on AIDS. Amsterdam 1992: PoB. 3304-3304
-
103 Bucher H C, Griffith L, Guyatt G H. et al .Meta-analyses of prophylactic treatments against PCP and toxoplasma.
-
104
Afessa B, Green W, Chiao J. et al .
Pulmonary Complications of HIV-Infection.
CHEST.
1998;
113
1225-1229
-
105
Waxmann A, Goldie S, Brett-Smith H. et al .
Cytomegalovirus as a primary pulmonary pathogen in AIDS.
CHEST.
1997;
111
128-134
-
106
Mylonakis E, Barlam T F, Flanigan T. et al .
Pulmonary aspergillosis and invasive disease in AIDS.
CHEST.
1998;
114
251-262
-
107
Stansell J D.
Fungal disease in HIV infected persons: Cryptococcosis, histoplasmosis, and coccidioidomycosis.
J Thorac Imaging.
1991;
6
28-35
-
108
Vuola J M, Ristola M A, Cole B. et al .
Immunogenicity of an inactivated mycobacterial vaccine for the prevention of HIV-associated tuberculosis: a randomized, controlled trial.
Aids.
2003;
17
2351-2355
-
109
Wahren B, Landay A.
HIV immunology better understood and vaccination attempts started.
Aids.
2002;
16 Suppl 4
S85-88
Prof. K. Dalhoff
Medizinische Klinik III, Universität Lübeck
Ratzeburger Allee 160
23538 Lübeck ·
Email: klaus.dalhoff@uni-luebeck.de
