Relationship of plasma cell-free DNA level with mortality and prognosis in patients with Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever (CCHF) is a viral infection. Circulating plasma cell-free DNA (pcf-DNA) is a novel marker indicating cellular damage. So far, the role of pcf-DNA did not investigate in CCHF patients. In the current study, pcf-DNA levels were investigated in CCHF patients with different clinical severity grades to explore the relationship between circulating pcf-DNA level, virus load, and disease severity. Seventy-two patients were categorized as mild, intermediate, and severe based on severity grading scores. The pcf-DNA level was obtained from all participants on admission and from the survivors on the day of the discharge. The controls consisted of 31 healthy. Although the pcf-DNA level at admission was higher in patients than in the controls, the difference was not statistically significant (P = 0.291). However, at admission and in the convalescent period, the difference between pcf-DNA levels in mild, intermediate, and severe patient groups was significant. The pcf-DNA level in severe patients was higher than in the others. Furthermore, compared to survivors, non-survivors had higher pcf-DNA levels at admission (P = 0.001). A direct relationship was found between the pcf-DNA level and the viral load on the day of discharge in surviving patients. ROC curve analysis identified a pcf-DNA level of 0.42 as the optimal cut-off for prediction of mortality. The positive predictive value, negative predictive value, specificity, and sensitivity for predicting mortality was 100%, 72%, 100%, and 79%, respectively. In summary, our findings revealed that pcf-DNA levels may be used as a biomarker in predicting CHHF prognosis.

[Evaluation of 10 cases of Lyme disease presenting with erythema migrans in Istanbul, Turkey]

Lyme disease (LD) is a tick-borne, multisystemic infection caused by Borrelia burgdorferi. Although variable rates of seropositivity for B.burgdorferi have been reported between 2% to 44% in Turkey, its actual prevalence is not well-understood. The aim of this retrospective study was to evaluate the characteristics of 10 cases of LD presenting as erythema migrans (EM) between 2009 and 2013 from Istanbul which is one of the metropolitan cities of Turkey. Of the patients, five were male and five were female, ages between 9-51 years (mean age: 34.5 years). Five of the patients were admitted in June, three in October, one in November and two in December and all have the history of tick bite in last 1-2 weeks. There were no clinical symptoms for systemic infection among the patients with normal level routine laboratory test (whole blood count and biochemical tests) results. Five of the cases had EM lesions in the trunk, three in the upper extremities, and two in the lower extremities. Four patients presented with annular, three with solitary macular, and three with target-like EM lesions. In all cases, the biopsy specimens were positive for B.burgdorferi sensu lato DNA with polymerase chain reaction and all were also positive in terms of B.burgdorferi IgM antibodies with ELISA. Nine patients were treated with oral doxycycline, 100 mg twice daily and one child patient was treated with oral amoxicillin 500 mg twice daily for 21 days. EM lesions disappeared within 2-4 weeks in all patients. There was no clinical evidence for systemic involvement in any of the patients like neurologic, cardiac, and joint involvement at the follow-ups on the third, sixth and 12(th) months. To our best knowledge, 10 patients in this study are the largest EM series reported from Turkey. The increase in the number of LD cases may be associated with increased tick bite and increased awareness due to the emergence of concurrent Crimean-Congo hemorrhagic fever epidemic in Turkey. As a result, when enlarged erythematous lesions on the skin were observed, LH must also be considered in differential diagnosis, history of tick bite should be questioned and etiological diagnostic test should be performed.

Crimean-Congo hemorrhagic fever among health care workers, Turkey

We investigated 9 cases of Crimean-Congo hemorrhagic fever (1 fatal, 2 asymptomatic) among health care workers in Turkey. Needlestick injuries were reported for 4 workers. Eight received ribavirin. In addition to standard precautions, airborne infection isolation precautions are essential during aerosol-generating procedures. For postexposure prophylaxis and therapy, ribavirin should be given.

Phenotypes and genotypes of macrolide-resistant streptococcus pneumoniae

BACKGROUND

Macrolide resistance in Streptococcus pneumoniae (S. pneumoniae) is a worldwide problem.

AIMS

The aim of this work was to analyze the phenotypes, genotypes, and clonal relatedness among macrolide-resistant S. pneumoniae strains isolated from various clinical specimens in our hospital.

STUDY DESIGN

Cross-sectional study.

METHODS

80 non-duplicate S. pneumoniae strains were analyzed by polymerase chain reaction for both the erm (B) and mef (A) genes.

RESULTS

Macrolide resistance was observed in 22.5% (18 strains) of strains. Two (11.2%) isolates possessed mef (A), eight possessed erm (B) (44.4%) and eight strains (44.4%) were positive for both erm (B) and mef (A) genes. Although BOX-PCR of 18 macrolide-resistant strains revealed 11 band patterns, they clustered as seven clones with a genetic distance >10% to each other. Eight isolates possessed both erm (B) and mef (A) genes and belonged to a single clone (44.44% of all macrolide-resistant strains).

CONCLUSION

Increased positivity rates for both resistance genes have also been reported from other hospitals in Turkey, but this is the first study from Turkey showing the clonal dissemination of both resistance genes.

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

OBJECTIVE

In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital.

METHODS

All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann-Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis.

RESULTS

There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (<40 years) (p=0.001), underlying chronic rheumatic heart disease (CRHD) (odds ratio (OR) 3.89) or a congenital heart defect (OR 4.04), community acquisition (OR 17.93), and native valve (OR 3.68). A staphylococcal aetiology was associated with healthcare acquisition (OR 2.26) or pacemaker lead-associated endocarditis (OR 6.63) and an admission creatinine level of >1.2mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality.

CONCLUSIONS

In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients.

The role of Porphyromonas gingivalis in the development of atherosclerosis and its relationship with fim A genotype

BACKGROUND

Porphyromonas gingivalis, a major periodontal pathogen, is gaining increasing attention for its possible association with atherosclerosis. Its fimbriae are classified into six genotypes (Types I-V, Ib) based on the diversity of the fim A genes encoding the fimbrial subunits. In this study, fim A genotype's distribution of P. gingivalis was analyzed in atherosclerotic plaque specimens.

METHODS

A total of 50 atherosclerotic plaque specimens and 50 non-atherosclerotic, post stenotic aneurysm specimens were collected from patients undergoing cardiovascular surgery. Bacterial DNA was also extracted from each specimen, as real-time PCR was carried out with P. gingivalis-specific primer sets. The positive specimens of P. gingivalis were further analyzed to discriminate the fim A genotype using real-time and nested PCR methods.

RESULTS

P. gingivalis was detected only in one atherosclerotic plaque; however, the genotype was nontypable in this specimen.

CONCLUSIONS

We state that it is not easy to show a significant relationship between P. gingivalis, its fim A genotype, and atherosclerosis. We suggest that new extended studies based especially upon the quantitave determination of P. gingivalis and its genotype distribution on atherosclerotic specimens are needed to show an evident relationship between atherosclerosis and P. gingivalis.

Predictors of fatality in pandemic influenza A (H1N1) virus infection among adults

Background

The fatality attributed to pandemic influenza A H1N1 was not clear in the literature. We described the predictors for fatality related to pandemic influenza A H1N1 infection among hospitalized adult patients.

Methods

This is a multicenter study performed during the pandemic influenza A H1N1 [A(H1N1)pdm09] outbreak which occurred in 2009 and 2010. Analysis was performed among laboratory confirmed patients. Multivariate analysis was performed for the predictors of fatality.

Results

In the second wave of the pandemic, 848 adult patients were hospitalized because of suspected influenza, 45 out of 848 (5.3%) died, with 75% of fatalities occurring within the first 2 weeks of hospitalization. Among the 241 laboratory confirmed A(H1N1)pdm09 patients, the case fatality rate was 9%. In a multivariate logistic regression model that was performed for the fatalities within 14 days after admission, early use of neuraminidase inhibitors was found to be protective (Odds ratio: 0.17, confidence interval: 0.03-0.77, p = 0.022), nosocomial infections (OR: 5.7, CI: 1.84-18, p = 0.013), presence of malignant disease (OR: 3.8, CI: 0.66-22.01, p = 0.133) significantly increased the likelihood of fatality.

Conclusions

Early detection of the infection, allowing opportunity for the early use of neuraminidase inhibitors, was found to be important for prevention of fatality. Nosocomial bacterial infections and underlying malignant diseases increased the rate of fatality.

Evaluation of the BD Phoenix system for detection of methicilin resistance in Staphylococcus aureus isolates in comparison to BD GeneOhm MRSA assay

BACKGROUND

In order to identify methicillin-resistant Staphylococcus aureus isolates quickly, automated and semiautomated systems, commercial media, and identification kits are widely used. The Phoenix system (BD, Sparks, MD, USA) has been available since 2004 in our laboratory. This study evaluated the reliability of the Phoenix system for the detection of methicillin resistance in Staphylococcus aureus isolates in comparison to BD GeneOhm MRSA assay (Becton Dickinson Diagnostics GeneOhm, CA, USA).

METHODS

A total of 206 clinically significant Staphylococcus aureus isolates, submitted to the clinical microbiology laboratory between March 2011 and May 2013, were included in the study. Phoenix panels were studied for identification and susceptibility testing according to manufacturers' instructions. The detection of MRSA was performed using the BD GeneOhm MRSA assay (Becton Dickinson Diagnostics GeneOhm, CA, USA). The assay is a qualitative real-time PCR method.

RESULTS

The Phoenix system results and mecA gene pozitivity were concordant for 134 methicillin-resistant and 71 methicillin-susceptible strains. One discordant isolate, identified as mecA negative by the PCR method, was methicillin-resistant Staphylococcus aureus positive by the Phoenix system (oxacilline MIC = 2 microg/mL; cefoxitin MIC = 8 microg/mL). In this study, Phoenix automated system's sensitivity, specificity, negative predictive value, and positive predictive value are found as 100%, 100%, 100%, and 100%, respectively.

CONCLUSIONS

As a result of our study, use of the Phoenix automated identification method for the detection of methicillin-resistant Staphylococcus aureus isolates is a practical and reliable approach for daily clinical laboratory procedures.

The effect of CD14 and TLR4 gene polymorphisms on asthma phenotypes in adult Turkish asthma patients: a genetic study

BACKGROUND

Endotoxins stimulate T helper 1 cell maturation and send a negative signal to T helper 2 polarisation. This causes a decrease IgE levels and prevents atopy (Hygiene hypothesis). It is shown that this response is under genetic control by polymorphisms in CD14 and TLR4 genes in some researchs. We aimed to investigate the effects of genetic variants of CD14 (-) and TLR4 (Asp299Gly, Thr399Ile) genes on asthma phenotypes in adults with asthma.

METHODS

Asthma patients (n = 131) and healthy control cases (n = 75) were included in the study. Relations between CD14 C-159 T, TLR4 299 and TLR4 399 genotypes and duration of asthma history of allergic rhinitis-dermatitis, total IgE, eosinophil, skin prick test, forced expiratory volume 1 (FEV1) and severity of disease were evaluated. Real time PCR (RT-PCR) was used for genotyping.

RESULTS

For CD14-159, presence of the C allele (CC + CT) was more frequent among those with low median log (logarithm) IgE levels, but no statistically significant difference in all asthma group (p = 0.09). C allele was significantly correlated with low total IgE levels and T allele with high total IgE levels in atopics (p = 0.04). CC + CT genotype was more frequent in moderate and severe asthma group in atopics (p = 0.049). TLR4 299 and TLR4 399 genotypes and asthma phenotypes were not found to be significantly correlated (p > 0.05).

CONCLUSIONS

Total IgE levels were found to be low among patients with the CC + CT genotype, and high among patients with the TT genotype contrary to the results of many other studies, which is therefore an important finding. Another important finding was that the C allele is a risk factor for moderate and severe asthma.

A fatal case of urosepsis due to Corynebacterium riegelii

Corynebacterium species other than Corynebacterium diphtheriae rarely cause infections in human but rather reside in flora, however they have been reported to cause opportunistic infections in both immunocompromised and immunecompetent patients. Here we report for the first time a case of an elderly female patient presenting with a fatal urosepsis caused by a recently defined pathogen, Corynebacterium riegelii, identified on second day after patient hospitalization leading to a progressive worsening and death of the patient on 6th day.

Nosocomial outbreak of disseminated orf infection in a burn unit, Gaziantep, Turkey, October to December 2012

We report the first outbreak of nosocomial orf infection in a hospital burn unit in Gaziantep, Turkey. The outbreak lasted from October to December 2012 and involved a total of thirteen cases. It demonstrates the risk of introduction of orf virus to a burn unit, and the potential for extensive transmission among patients with compromised skin integrity. The importance of hygiene measures and infection control are highlighted and possible transmission routes of the virus discussed.

Varicella gastritis in an immunocompetent child

The varicella zoster virus (VZV) is a very rare cause of gastritis. Gastritis caused by VZV can be presented as abdominal pain, vomiting. Most of the cases reported with varicella gastritis in the literature are immunocompromised patients with various kinds of malignancy, and most of these patients are adults. Here we report an adolescent girl with acute abdominal pain. The girl was immunocompetent. Her endoscopically taken biopsy material revealed varicella, and her gastritis was healed with acyclovir therapy. This is a very rare condition and not frequently reported in the literature. The authors want to drive attention to the fact that varicella gastritis can be seen in immunocompetent children, the presentation can be nausea, vomiting and/or (severe) abdominal pain. Serological studies may be less helpful than tissue studies, so interventional procedures should be done.

Rickettsia species in ticks removed from humans in Istanbul, Turkey

A total of 167 ticks collected from humans in Istanbul (Turkey) in 2006 were screened for Rickettsia species, and nested PCRs targeting gltA and ompA rickettsial fragment genes were carried out. Rickettsia monacensis (51), R. aeschlimannii (8), R. conorii subsp. conorii (3), R. helvetica (2), R. raoultii (1), R. africae (1), R. felis (1), and other Rickettsia spp. (2), were detected. To our knowledge, these Rickettsia species (except R. conorii) had never been reported in ticks removed from humans in Turkey. The presence of R. africae also had not been previously described, either in Hyalomma ticks or in any European tick species. In addition, R. aeschlimannii and R. felis had not been found associated with Rhipicephalus bursa specimens. The presence of human pathogenic Rickettsia in ticks removed from humans provides information about the risk of tick-borne rickettsioses in Turkey.

Novel influenza a (H1N1) infection in a Pediatric Hematology Oncology Clinic during the 2009-2010 pandemia

Pandemic influenza A infection (2009 H1N1) was associated with a worldwide outbreak of febrile respiratory infection. Although usually it results in a mild illness, certain patient groups are at increased risk for complications. The authors reviewed their experience in a pediatric hematology-oncology unit to determine the outcome of this disease in children with hematological conditions and solid tumors. During the second outbreak (1 November 2009 to 14 January 2010), a total of 187 children from pediatric clinic were tested for H1N1 influenza A by multiplex polymerase chain reaction (PCR), 63 of them were positive. Patients' signs and symptoms were recorded prospectively. Ten (35.7%) (5 children with solid tumors, 4 with leukemia, 1 with hereditary spherocytosis) of 28 tested children with hematological conditions were diagnosed with 2009 H1N1 influenza infection. Fever (100%) and cough (90%) were the most common symptoms. Five were neutropenic (neutrophil count <1000/mm(3)), 4 had severe neutropenia (neutrophil count <500/mm(3)). Systemic antibiotics were given in 5 patients with the diagnosis of febrile neutropenia. Four were inpatients, others were hospitalized after the diagnosis. One patient required mechanical ventilation; however, he had concomitant invasive fungal infection. Eight patients were treated by oseltamivir, all tolerated the drug well. A total of 4 cases from 9 cancer patients had a delay in their planned chemotherapy for 7 to 15 days. Pandemic H1N1 influenza caused mild symptoms in children with cancer and/or hematological conditions but resulted in delay in anticancer therapy and increase in hospitalization and antibiotic usage.

A cluster of acute-onset postoperative endophthalmitis over a 1-month period: investigation of an outbreak caused by uncommon species

AIM

To report the clinical course, treatment response and prognosis of eight cases which developed acute-onset postoperative endophthalmitis over a 1-month period.

METHODS

8 patients who were operated on over a period of 1 month and developed acute postoperative endophthalmitis were evaluated. Five of the patients had cataract surgery, one had cataract surgery combined with silicone extraction, and two patients had pars plana vitrectomy (PPV). Clinical patterns were observed, intraocular cultures were obtained, and the source of the organisms causing the epidemic was investigated. All patients had intravitreal antibiotic injections, three had PPV, and in two patients anterior chamber irrigation was performed.

RESULTS

Vitreous cultures showed Cellulosimicrobium cellulans in three cases and Stenotrophomonas maltophilia in one case. Four of the cases were culture negative. Stenotrophomonas maltophilia were also isolated from unused bottles of irrigating solutions. The final visual acuity of the patients ranged between HM and 7/10. All three patients with Cellulosimicrobium cellulans had a final visual acuity of ≥ 5/10. The available irrigating solutions were changed, and the endophthalmitis did not recur.

CONCLUSIONS

The authors are unaware of any previous reports of postoperative endophthalmitis associated with Cellulosimicrobium cellulans. Prompt management with microbiological support, intravitreal antibiotics and PPV when needed were the key to good visual outcomes in this endophthalmitis outbreak.

[Detection of human bocavirus DNA by polymerase chain reaction in children and adults with acute respiratory tract infections]

Human bocavirus (HBoV) which was described in 2005 by molecular techniques, is a member of Parvoviridae. The role of HBoV is being questioned in acute respiratory diseases (ARD) in many recent studies. The aim of this study was to determine the presence of HBoV DNA in the respiratory specimens of patients with ARD. A total of 155 throat swab and/or washing specimens from 76 children and 79 adults with ARD were examined. HBoV DNA was investigated by single step in-house polymerase chain reaction (PCR) using NS1 primers (5-'TATGGCCAAGGCAATCGTCCAAG-3', 5'-GCC GCGTGAACATGAGAAA-CAG-3') which amplify the 290 base pair region of NS1 gene located between nucleotides 1545-1835 of prototype HBoV st1 strain. HBoV DNA was detected in 5 (6.5%) of 76 children and 2 (2.5%) of 79 adults. Three sequenced samples showed 100% homology with the reference sequences. This study in which HBoV DNA was detected in children and adults with ARD, is the first HBoV prevalence study in Turkey. Larger scale prospective clinical and molecular studies are required to explain the association between HBoV and respiratory disease.