Foodborne botulism in Turkey, 1983 to 2017

OBJECTIVE

The aim of this study is to assess the epidemiology of foodborne botulism cases which were seen and published in Turkey.

MATERIAL AND METHODS

This study covers the cases and outbreaks of botulism that have been identified and published in any region of Turkey, between 1983 and 2017. This systematic review was performed in accordance with the guidelines for performing and reporting systematic reviews and meta-analyses. The search was done on PubMed and Google in English and Turkish languages. Demographic features of the cases, nutritional sources, the development process of the disease, clinical symptoms and signs, the duration of hospitalization, treatment and mortality rates were analyzed.

RESULTS

Totally 95 patients (57 female and 38 male) were assessed from the published. The food which caused the majority of intoxication cases was canned green beans, and all the foods were home-canned goods. There cords showed that botulism antitoxin was given to 56 patients. The time from exposure to illness onset was 26.9 h. While 18 patients died at the end of follow-up and treatment (mortality 19%), 77 patients were discharged with full recovery.

CONCLUSION

Among 95 botulism cases, spread in Turkey over the last 35 years, the predominant source of toxin was home-canned food and green beans, in particular. Since community and emergency room physicians may be the first to treat patients with any type of botulinum intoxication, they must know how to diagnose and treat this rare but potentially lethal disease.

Non-invasive fibrosis tests are correlated with necroinflammatory actvity of liver in patients with chronic hepatitis B

BACKGROUND

The gold standarda method used for assessing necroinflammatory activity and fibrosis in the liver is a liver biopsy which has many disadvantages. Therefore, many investigators have been trying to develop non-invasive tests for predicting liver fibrosis score (LFS) of these patients. The aim of this study is to describe the relationship between certain non-invasive fibrosis markers with LFS and histological activity index (HAI) detected histopathologically by liver biopsy in chronic hepatitis B patients.

MATERIALS AND METHODS

A total of 54 patients who had undergone a liver biopsy with the diagnosis of chronic HBV infection were included in the study. Ishak scoring was used for the evaluation of liver fibrosis, and a modified Knodell HAI was used for demonstration of necroinflammation. In this study, non-invasive fibrosis tests were calculated as described in previous studies.

RESULTS

Histological acitivity index was positively correlated with age, age/platelet index, cirrhosis discriminant score (CDS), AST/platelet ratio index (APRI), AST/platelet/GGT/AFP index (APGA), fibro-quotient (Fibro-Q), Goteburg University Cirrhosis Index (Guci), and Platelet/Age/Phosphatase/AFP/AST index (PAPAS). When divided into two groups according to HAI, Guci and APGA were found significantly different both in >4 and >4 HAI groups than the other group. In ROC analysis performed for LFS; PAPAS, APGA, FFI and APRI were the markers having the highest AUC levels, and in ROC analysis performed for HAI; Guci, APRI and APGA were the markers with the highest AUC levels.

CONCLUSIONS

APRI, APGA and GUCI tests may be helpful in prediction of necroinflammatory scores in the liver.

Seroprevalence of human fascioliasis in Van province, Turkey

BACKGROUND/AIMS

Fasciola hepatica is a rare zoonotic parasite that infects the liver of many mammals including humans. The aim of this study was to determine the seroprevalence of fascioliasis in Van province by ELISA (antibody detection) on the assumption that not all cases could be detected by stool examination alone.

MATERIALS AND METHODS

A total of randomly selected 1,600 patients, directed from affiliated outpatient clinics to Yüzüncü Yıl University Medical Faculty Parasitology Laboratory, were enrolled in the study. Their mean age was 44.44±19.00 years. Blood samples were collected from all the patients, and their stool samples were examined. For the stool examination, native-lugol and sedimentation (in formalin-ethyl acetate) methods were employed. ELISA for F. hepatica was performed on the blood samples from all patients. Seropositive patients were treated with triclabendazole.

RESULTS

F. hepatica was detected by ELISA in 89 (5.6%) of the 1,600 patients, but eggs were identified on the stool examination in only 29 (1.8%) patients. The prevalence of F. hepatica was higher in females (7.2%) than in males (4.2%) and was higher in the ≥36-year age group (6.7%) than in the ≤35-year age group (4.4%). Abdominal pain (93.3%), fatigue (88.8%), and weight loss (69.7%) were the most common symptoms. Eosinophilia was present in 89.9% of the patients. All seropositive patients had a history of eating raw aquatic plants.

CONCLUSION

Stool examination alone is not sufficient to diagnose F. hepatica. Serological tests such as ELISA must be used together with stool examination.

High asymmetric dimethylarginine (ADMA) levels in patients with brucellosis

Asymmetric dimethylarginine (ADMA) is the main endogenous inhibitor of nitric oxide synthase and is considered to be associated with endothelial dysfunction. Brucellosis, a zoonotic disease caused by Brucella spp., can manifest as vasculopathy. The present study was performed to investigate the relationship between ADMA and brucellosis. Serum samples from 39 patients with an accurate diagnosis of brucellosis and from 18 healthy control individuals were included in this study. ADMA levels were significantly higher in the patient group than the controls (P < 0.001). Receiver operating characteristic (ROC) curve analysis indicated that ADMA level ≥ 0.61 had a sensitivity of 79.5 %, specificity of 88.9 %, positive predictive value of 93.9 %, and negative predictive value of 66.7 %. This is the first report of an association between brucellosis and high levels of ADMA. In conclusion, ADMA levels should be tested in brucellosis cases and that further studies to clarify the mechanism underlying the association between ADMA and brucellosis are required.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

The Syndrome of Inappropriate Secretion of AntiDiuretic Hormone in Patients With Brucellosis

OBJECTIVE

Various studies have shown that a number of infectious disease causes syndrome of inappropriate antidiuretic hormone (SIADH). However, the relationship between infectious disease and SIADH is not yet fully known. In this prospective study, we aimed to assess the presence of SIADH in patients with brucellosis.

PATIENTS AND METHODS

Thirty-five patients with acute brucellosis were retrospectively reviewed. The diagnosis of brucellosis was performed using the Wright test in connection with blood culture. SIADH was defined by euvolemic hyponatremia (serum sodium level lower than 135 mEq/l) with increased urinary sodium excretion (urinary sodium higher than 40 mmol/l).

RESULTS

Of the 35 patients, 19 (54%) had SIADH; 20 (57%) also had hypouricemia (uric acid level lower than 4 mg/dl). Additionally, all of the studied patients had a high mean urinary sodium excretion rate (mean 132 mmol/l; range 40-224). Most importantly, the hyponatremic patients were more likely to have a lower albumin level (P < 0.01).

CONCLUSIONS

SIADH is a major complication of brucellosis. The presence of SIADH could be a diagnostic tool for diagnosing brucellosis. Further larger randomized studies may confirm these findings.

Asymmetric dimethylarginine levels in patients with cutaneous anthrax: a laboratory analysis

BACKGROUND

Asymmetric dimethylarginine (ADMA), the main endogenous inhibitor of nitric oxide synthase, is considered to be associated with endothelial dysfunction. High ADMA levels have been shown to be related with disorders causing vascular inflammation such as hypertension, hypercholesterolemia, atherosclerosis, chronic heart failure, stroke and sepsis. Cutaneous anthrax (CA) is a serious infectious disease which may cause vasculitis. The aim of the study was to investigate the serum ADMA levels in patients with CA.

METHODS

A total of 35 serum samples of the patients with CA and 18 control sera were tested for ADMA levels using ADMA ELISA kit (Immunodiagnostik AG, Bensheim, Germany).

RESULTS

ADMA levels were found to be significantly higher in the patients group than the controls (p < 0.001). In addition, ADMA levels were found to be positively associated with sedimentation rates (R = 0.413; p = 0.026), and inversely associated with international normalized ratio (INR) levels (R = -0.46; p = 0.011). A cut-off value of 0.475 of ADMA had a sensitivity of 74.3%, specificity of 77.8%, and accuracy of 75.5% in the diagnosis of CA.

CONCLUSION

Although the exact mechanism still remains unclear, ADMA levels could be related to immune activation in CA. In addition, these data might suggest the higher ADMA levels in patients could be due to the perivascular inflammation and vasculitis in CA.

Evaluation of patients with Tularemia in Bolu province in northwestern Anatolia, Turkey

INTRODUCTION

Tularemia is a zoonotic disease caused by Francisella tularensis. Here we present an epidemic occurring in Bolu province, located in northwestern Anatolia in Turkey, and some features of the cases.

METHODOLOGY

The data was provided by the Bolu Provincial Health Directorate. All of the antibody response tests were studied in the National Health Institute (formerly named Refik Saydam Hygiene Department), the reference laboratory of the Ministry of Health of the Turkish Republic. A total of 393 individuals were tested by microagglutination test (MAT) for tularemia between 2006 and 2011. A total of 218 patients whose demographical data were available were included in the study; 83 were accepted as the patient group and 135 were the controls. Of the patients, 31 (37.3%) were male and 52 (62.7%) were female.

RESULTS

Fever (p < 0.001), URTI symptoms (p = 0.047), conjunctivitis (p = 0.004), and rash (p = 0.026) were significantly higher in the patient group. A positive association was found between MAT and fever (r = 0.324; p < 0.001), and a negative association was found between MAT and both lymphoadenopathy (r = -0.25; p = 0.013) and chills (r = -0.218; p = 0.035). Higher MAT titers were detected in oropharyngeal tularemia (r = 0.306; p = 0.003).

CONCLUSIONS

In conclusion, tularemia must be considered in differential diagnosis in patients presenting with fever and LAP in non-endemic regions. Furthermore, water sources and contact with rodents must be investigated.

Nosocomial Acinetobacter baumannii Infections and Changing Antibiotic Resistance

Objectives: In the intensive care setting, Acinetobacter baumannii causes ventilator-associated pneumonia and other nosocomial infections that are difficult to treat. Objective of this study was to investigate nosocomial A. baumannii infections and its changing antibiotic resistance.

Methods: A total of 56 patients diagnosed with A.baumannii infections between January 2009 and December 2011 were included in the study. Diagnosis for nosocomial infections was established according to the CDC (Centers for Disease Control and Prevention) criteria. Identification of the agents isolated was carried out using conventional methods and VITEK 2 automated system, while antibiotic sensitivity testing was performed through VITEK 2 AST-N090 automated system.

Results: The most common infection was nosocomial pneumonia by 43%, among which 46% were ventilator-associated pneumonia. Considering all years, the most effective antibiotics on the isolated strains were found as colistin, tigecycline, imipenem and meropenem. However resistance to imipenem and meropenem was observed to increase over years.

Conclusion: The issue of increased resistance to antibiotics poses difficulty in treatment of A. baumannii infections which in turn increases the rate of mortality and cost. In order to prevent development of resistance, antibiotics must be used in an appropriate way in accompanied with proper guidance.

Efficacy of daptomycin on experimental methicillin-resistant Staphylococcus aureus keratitis in rabbits

PURPOSE

We aimed to compare the efficacy of topical daptomycin (DAP) with that of vancomycin (VA) in the treatment of keratitis caused by methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

One hundred colony-forming unit MRSA bacteria were injected intrastromally into both corneas of 28 rabbits. Sixteen hours after injection, the rabbits' eyes were treated with 1 drop of topical DAP (10 or 50 mg/mL), VA (50 mg/mL), or isotonic saline for 19 doses. Their eyes were examined for clinical severity before and after treatment.

RESULTS

The minimum inhibitory concentration values of VA and DAP against the bacterial strain were found to be 2 and 0.5 μg/mL, respectively. The mean pre- and post-treatment clinical scores of the eyes did not differ significantly among the groups. However, the mean difference between the post- and pretreatment clinical scores was significantly lower in the 50 mg/mL DAP group than in the other groups (P=0.042). A marked decrease in bacterial load was detected in all treatment groups compared to the control group (P=0.002). Although there were no significant differences in bacterial load among the treatment groups, the 50 mg/mL DAP group showed the greatest decrease. The mean % epithelial erosion rate tended to be higher in the 50 mg/mL VA group than in the other groups (P=0.31).

CONCLUSIONS

Topical DAP significantly reduced the bacterial load and showed activity against MRSA comparable to that of fortified VA in this experimental model.

Cutaneous anthrax resulting in renal failure with generalized tissue damage

Anthrax is a zoonotic infection caused by Bacillus anthracis which can be clinically present in a cutaneous, gastrointestinal or inhalational form depending on the entry site of the agent. The most frequent clinical type with the mildest clinical course is cutaneous anthrax. In this report, a patient with cutaneous anthrax which begins at the dorsal hand and progresses up to the proximal forearm resulting in massive tissue damage is presented. Prerenal azotemia developed due to massive tissue damage and patient was sent to hemodialysis twice.

Could thrombocyte parameters be an inflammatory marker in the brucellosis?

AIM

To investigate links between platelet parameters mean platelet volume (MPV), platelet count (PC), platelet distribution width (PDW), platelet mass (PM) and brucella tube agglutination titers (BSTAT) in patients with brucellosis. Initially, PC, MPV, PM and PDW calculations were compared between periods before and after treatment. The correlation between inflammation markers (erythrocyte sedimentation rate, ESR, white blood cell count, WBC, and C reactive protein, CRP) and platelet parameters was subsequently investigated.

METHODS

This self-controlled study included 40 patients who had positive BSTAT at least at a titer of 1/160. Platelet parameters and inflammation values (CRP, ESR) at the time of positive BSTAT at least at a titer of 1/160 (pre-treatment) were compared with control of the same parameters at the time when BSTAT became negative or when the titers reduced 4 folds (post-treatment).

RESULTS

Mean platelet volume values (7.90+1.96) were significantly elevated in post treatment period when compared to pre treatment (7.58+1.96), (p= 0.023). Post treatment CRP, ESR and PC were significantly reduced when compared to pretreatment values (p=0.000, p=0.000 and p=0.025, respectively). In the pretreatment period, a direct correlation between ESR and PC values (r=0.036, p=0.025), and inverse correlations between ESR with MPV (r=-0.337, p=0.038) was found. A dependent predictive factor in multivariate logistic regression analysis for BSTAT was not found.

CONCLUSION

We suggest that PC and MPV may be inflammatory markers in brucellosis.

Determining immunoassay cutoff value using Western blot results to predict hepatitis C infection in blood donors with low-titer anti-HCV reactivity

Since the 1990s, blood donors have been scanned for anti-hepatitis C virus (anti-HCV) antibodies, which can be defined by enzyme immunoassay as a screening test. In this population, false-reactive ratios have been high. Recently, some authors have aimed to find a cutoff value for anti-HCV different from those established by test manufacturers to predict HCV infection. In this study, 321 patients, after two repeating tests, had reactive results in s/co <10 titers on anti-HCV test. The patients were 29.6 % (n = 95) in women and 70.4 % (n = 226) in men. The patients were classified into three groups by Western blot (WB) results (PS, positive; NG, negative; and ID, indeterminate). The average anti-HCV titer of the whole group was 2.61 ± 1.96. Anti-HCV titers of subgroups were 2.43 ± 1.95 in NG, 4.93 ± 2.53 in PS, and 2.50 ± 1.65 in ID (p < 0.001). There was a significant difference between NG and PS and between PS and ID subgroups (p < 0.001). There was a positive correlation between WB and anti-HCV titers in all patients (r = 0.298, p < 0.001), in women (r = 0.282, p < 0.001), and in men (r = 0.337, p = 0.002). According to receiver operator characteristic curve analysis, the cutoff value of anti-HCV titer to predict hepatitis C infection was >2.61 s/co, with 74.1 % sensitivity and 71.6 % specificity (area under the curve, 0.820; 95 % confidence interval, 0.753 to 0.887). We suggest that an effective cutoff value for anti-HCV other than that established by the manufacturer cannot be assigned to predict hepatitis C infection for blood donors in low-prevalence areas.

Significance of bacteriuria and leukocyturia in the outpatients with heart failure

AIM

To investigate the relationship between severity of illness and hospitalization with the presence of leukocyturia and bacteriuria in outpatients with heart failure (HF).

PATIENTS AND METHODS

Four hundred three patients admitted with the diagnosis of HF to cardiology outpatient clinic were included in this study. According to New York Heart Association (NYHA) classification, the patients were divided into two groups to be group A (decompensated) as stage 3 or 4 and group B as stage 1 or 2 (compensated HF). All subjects underwent standard 12-lead ECG and echocardiography. In all patients, full blood, biochemical tests as liver and kidney function tests, full urinary analysis (FUA) and thyroid function tests were analyzed. Mid-stream urine for culture was taken for the leukocytes number > or =5 mm3.

RESULTS

The mean leukocyte number (MLN) in urine of patients was 16.56 +/- 13.63 in Group A and was 3.74 +/- 5.31 in Group B (p < 0.000). The moderately positive correlation was found between the MLN and NHYA class in all patients (r = 0.526; p < 0.000). In receiver operating characteristic (ROC) curve analysis, the optimal cut-off value of leukocytes in urinalysis to predict hospitalization of CHF was > or =5, with 76.1% sensitivity and 75.7% specificity (area under the curve 0.825, 95% confidence interval 0.781 to 0.862, p = 0.000).

CONCLUSIONS

We found that the numbers of leukocytes in urinalysis of hospitalized patients with HF were significantly higher than non-hospitalized persons. Also, number of leukocyte in urinalysis was positively correlated with NYHA class of HF patients. Namely, leukocyturia may be an indicator of decompensations in HF patients.

Bone marrow biopsy findings in brucellosis patients with hematologic abnormalities

BACKGROUND

Brucellosis can mimic various multisytem diseases, showing wide clinical polymorphism that frequently leads to misdiagnosis and treatment delay, further increasing the complication rates. In this study, we aimed to examine bone marrow biopsy findings in brucellosis cases presenting with hematologic abnormalities.

METHODS

Forty-eight brucellosis cases were prospectively investigated. Complaints and physical examination findings of patients were recorded. Patients' complete blood count, routine biochemical tests, erythrocyte sedimentation rate, C-reactive protein and serological screenings were performed. Bone marrow biopsy and aspiration was performed in patients with cytopenia, for bone marrow examination and brucella culture, in accordance with the standard procedures from spina iliaca posterior superior region of pelvic bone.

RESULTS

Of the 48 patients, 35 (73%) were female and 13 (27%) were male. Mean age was (34.8 ± 15.4) years (age range: 15 - 70 years). Anemia, leukopenia, thrombocytopenia and pancytopenia were found in 39 (81%), 28 (58%), 22 (46%) and 10 patients (21%), respectively. In the examination of bone marrow, hypercellularity was found in 35 (73%) patients. Increased megacariocytic, erythroid and granulocytic series were found in 28 (58%), 15 (31%) and 5 (10%) patients, respectively. In addition, hemophagocytosis was observed in 15 (31%) patients, granuloma observed in 12 (25%) and increased eosinophil and plasma cells observed in 9 (19%) patients.

CONCLUSION

According to the results of our series, hemophagocytosis, microgranuloma formation and hypersplenism may be responsible for hematologic complications of brucellosis.

Naturally Occurring Cutaneous Anthrax: Antibiotic Treatment and Outcome

<i>Objectives:</i> Cutaneous anthrax (CA) is the most common clinical presentation in human anthrax, but the duration of antibiotic therapy in naturally occurring CA is controversial. The aim of this study was to compare the clinical outcomes of patients receiving antibiotic treatment for either 3-5 days (group 1) or 7-10 days (group 2) in uncomplicated CA. <i>Methods:</i> A total of 66 patients were enrolled; 29 (44%) in group 1 and 37 (56%) in group 2. Infections were classified as mild (n = 22, 33%) or severe (n = 44, 67%) CA. <i>Results:</i> There were no significant differences between the groups in symptom resolution time, fever clearance time, healing of lesions, development and healing of eschars, requirement for surgical intervention or the development of complications. Both edema resolution time and duration of hospital stay were longer in group 2. There were no therapeutic failures, relapses or deaths in either group. Steroid therapy was used in 32% of patients with severe CA, but a beneficial effect on resolution of edema was not demonstrated. <i>Conclusions:</i> These results suggest that short-course antibiotic therapy is as effective as standard-duration therapy in uncomplicated CA and that steroid therapy may not be effective.

A familial outbreak of fascioliasis in Eastern Anatolia: a report with review of literature

AIM

To present the results of a cross-sectional epidemiological analysis of a familial outbreak of fascioliasis in Eastern Anatolia and to discuss the clinical, diagnostic and therapeutic properties of the patients.

MATERIALS AND METHODS

A screening group consisting of 92 individuals from the same family with a history of watercress ingestion and a control group consisting of 30 individuals from neighboring families were included in the study. In both groups, full blood count, erythrocyte sedimentation rate, liver function tests and total IgE levels were assessed. Stool analysis was performed on three consecutive days with native, lugol and sedimentation methods. The diagnosis was based on the detection of parasite ova in the stool or alternatively based on consistent clinical, laboratory, and radiological findings or positive clinical findings in combination with a positive ELISA test. Abdominal ultrasonography and computerized tomography scans were performed on all patients.

RESULTS

24 patients (21 women and 3 men) were diagnosed with fascioliasis. The mean age was 24.5±18.6 years (range, 5-64 years). All cases had a history of watercress ingestion, malaise, fatigue, lack of appetite, and abdominal pain. Clinical features included: weight loss was present in 18 cases (75%), dyspepsia in 12 (50%), headache in 11 (45.8%), sweating in 10 (41.7%), fever and dyspnea each in 8 (33.3%), nausea and vomiting in 6 (25%), and itching in 4 (16.75). The most common laboratory abnormalities were total IgE elevation in 19 cases (79.2%) and eosinophilia in 17 (70.8%). The eosinophilia was >20% in 14 cases (58.3%) and the total IgE was >500IU/ml in 15 cases (62.5%). Stool examination for ova was positive in 11 cases. 10 patients had positive clinical, laboratory and radiological findings. A further three patients were diagnosed based on their clinical findings and their ELISA results. All cases had positive ELISA results. All patients, except one pregnant woman, were treated with 10mg/kg triclabendazole. Two patients required a second treatment course of triclabendazole 20mg/kg in two divided doses due to persistence of ova in the stool. One patient who developed acute urticaria as a side effect of the drug was given three additional courses of 10mg/kg triclabendazole in combination with prednisolone and antihistamines. The pregnant woman initially received four courses of 25mg/kg praziquantel treatment for 1 week. As ova were still detected in her stool following delivery, she was subsequently treated with triclabendazole.

CONCLUSIONS

One case of fascioliasis may indicate a familial outbreak. In the acute stage radiological investigations can assist in confirming the diagnosis. ELISA testing is a reliable and sensitive method for the diagnosis of fascioliasis during any stage of the disease and may also be useful during follow-up.

Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature

INTRODUCTION

Brucellosis is the most prevalent bacterial zoonosis worldwide. In this study, we aimed to compare our 1028 brucellosis cases with other big series in the literature in view of epidemiological, clinical, and laboratory findings and therapeutic features.

METHODS

A total of 1028 brucellosis cases admitted to the Department of Infectious Diseases and Clinical Microbiology over a 10-year period were included in the study. A retrospective analysis was undertaken and patient files were reviewed for history, clinical and laboratory findings, and therapeutic features, as well as complications.

RESULTS

Of the 1028 patients, 539 (52.4%) were female and 489 (47.6%) were male. The mean age of patients was 33.7+/-16.34 years and 69.6% of cases were aged 13-44 years. Four hundred and thirty-five cases (42.3%) had a history of raising livestock and 55.2% of the cases were found to have no occupational risk for brucellosis. Six hundred and fifty-four of the cases (63.6%) had a history of raw milk and dairy products consumption. The most frequently seen symptoms were arthralgia (73.7%) and fever (72.2%), while the most common clinical findings were fever (28.8%) and hepatomegaly (20.6%). The most frequent laboratory finding was a high C-reactive protein level (58.4%). The standard tube agglutination (STA) test+Coombs STA test was positive in 1016 cases (98.8%). Focal involvement was present in 371 (36.1%) cases. The most frequent involvement was osteoarticular involvement with 260 cases (25.3%). The overall relapse rate for patients with brucellosis was 4.7%. The highest relapse rate, 8.5%, was observed in the group of patients with osteoarticular involvement. Regimens including doxycycline and streptomycin with or without rifampin appeared more effective than other regimens in osteoarticular involvement.

CONCLUSIONS

In humans, brucellosis may lead to serious morbidity, and it continues to be a major health problem in Turkey. There is no recommended treatment protocol for complicated brucellosis. Large multicenter studies are needed to determine the most appropriate treatment choices and durations in complicated brucellosis.

Toxic-febrile neurobrucellosis, clinical findings and outcome of treatment of four cases based on our experience

Central nervous system (CNS) involvement is uncommon in brucellosis. Neurological complications of brucellosis may be divided into 2 major groups: 1) those related to the acute-febrile state that occurs in acute disease (toxic-febrile neurobrucellosis), and 2) those related to actual invasion and localization of the pathogen in the CNS (classical neurobrucellosis). In this paper, we present 4 cases of toxic-febrile neurobrucellosis and discuss clinical findings and outcome of treatment in these cases. All patients had fever, headache, stupor or coma with neuropsychiatric symptoms such as hallucination, delirium, convulsion, dysarthria, psychosis, and night raving. Peripheral and cranial vasculitis was present in case 3 and bilateral sensorioneural hearing loss in case 4. Neither pleocytosis nor hyperproteinorrachia was present in any patient in lumbar puncture. Brucella melitensis was isolated in case 3 from bone marrow, and in case 4 both from blood and bone marrow. All patients received combined treatment consisting of ceftriaxone, rifampicin, and doxycycline. They were discharged from the hospital with full recovery. No recurrence or any complaint was observed during the follow-up. In conclusion, despite the rapid course and serious complications, outcome from febrile-toxic neurobrucellosis is excellent especially when effective antimicrobial therapy is started early in the course of illness.

An outbreak of botulism in a family in Eastern Anatolia associated with eating süzme yoghurt buried under soil

Cases of botulism in a family in eastern Anatolia were studied. In late September 2005, an outbreak of botulism developed in our region, first in 2 patients, a teenage boy and his mother, in whom the disease culminated in respiratory insufficiency and death. An additional 8 cases of botulism were identified later; most of them presented to our medical centre the next d. These patients with milder symptoms recovered gradually. All the patients received anti-botulinum toxin. The investigation of the source of the outbreak showed an unexpected vehicle for botulism infection in the these patients, süzme (condensed) yoghurt buried under soil. Type A botulinal toxin was detected in the yoghurt sample. The clinical diagnosis was also confirmed by a mouse bioassay performed with the serum samples of the patients. The most common symptoms were dry mouth, difficulty in speaking and swallowing, and change in voice quality. The 10 identified patients with botulism constitutes the largest-ever outbreak of botulism reported in Turkey to date. The present study shows the importance of considering a diagnosis of botulism soon after patients present with acute cranial nerve dysfunction and of promptly treating suspected cases with antitoxin.

Brucellosis in pregnancy: a 6-year clinical analysis

AIM

To review our experience with brucellosis in pregnancy and to characterize the risk factors, clinical presentations, the rates of possible perinatal complications, and the effect of hospitalization on pregnancy outcomes.

METHODS

We reviewed the medical records of 21 pregnant women at a tertiary care hospital and 12 at a maternity hospital, who presented with acute, subacute, chronic, or relapsing brucellosis. Their risk factors and clinical presentations were defined. The reproductive outcomes of 29 cases were compared within themselves according to the hospitals they were managed and with the outcomes for all women followed in the maternity hospital for the period from January 2008 through December 2008.

RESULTS

Consumption of unpasteurized dairy products had occurred in 92.3% of the cases. Spontaneous abortion, intrauterine fetal death, and preterm delivery rates were 24.14, 3.45, and 6.9%, respectively. Only spontaneous abortion rate substantially exceeded that among the general population of pregnant women in our maternity hospital (P<0.05). Hospitalization did not affect pregnancy outcomes significantly (P>0.05).

CONCLUSIONS

Brucellosis in pregnancy is associated with increased incidence of spontaneous abortion without an association with the magnitude of serum agglutination titer, the clinical type of brucellosis and hospitalization. In endemic areas with inhabitants of low socioeconomic class and low educational level, educating women of childbearing age about brucellosis may help to prevent the disease and its complications in pregnancy.

[Case report: two Plasmodium vivax malaria cases in the Van Province]

Malaria is an important parasitic infection which is endemic in the Eastern Mediterranean and Southeastern Anatolia regions and sporadic in other regions of Turkey, while Plasmodium vivax is the most common cause. Two patients who were admitted to our hospital in October with complaints of high fever, chills, nausea-vomiting, generalized body pain and fatigue and diagnosed as P. Vivax malaria are presented, because they were two brothers with no history of travel outside of Van city.

Cutaneous anthrax in Eastern Turkey: a review of 85 cases

BACKGROUND

Anthrax is a zoonotic disease diminishing worldwide. Although a very rare disease in developed countries, anthrax is still endemic in developing countries.

AIM

To evaluate the clinical history and features, treatment and outcome of our patients with anthrax and emphasize the importance of the disease in our region.

METHOD

In this study, the records of all patients diagnosed with cutaneous anthrax admitted to Yüzüncü Yil University Medical Faculty between March 2002 and March 2007, were reviewed, and data on age, gender, occupation, clinical symptoms and findings, location and type of lesions, clinical history, laboratory findings, treatment and outcome were recorded.

RESULTS

There were 85 patients [46 (54.1%) male, 39 (45.9%) female; mean age 30.6 years, range 6-72]. All the patients had a history of contact with infected animals or animal products. The infectious agent was found using direct examination of Gram-stained smears from 17 patients (20%), and Bacillus anthracis was isolated from vesicle fluid cultures from 11 patients (12.9%). Diagnosis was based on clinical findings in the remaining 57 patients (67.1%). All patients, except for two with respiratory tract obstruction, made a full recovery.

CONCLUSION

Anthrax continues to be an endemic disease in Turkey, and should be considered in patients with a relevant contact history having a painless ulcer and vesicular skin lesions surrounded by a zone of oedema. Gram staining and simple culture methods are useful aids to diagnosis, but diagnosis may have to be based on clinical grounds in the majority of patients.

Apparent vaccine-thimerosal induced hypersensitivity, myelodysplastic syndrome and pancytopenia

A case of hypersensitivity reaction, myelodysplastic syndrome and pancytopenia, which developed after an administration of thimerosal-containing tetanus vaccine, is presented and discussed.

Apparent vaccine-thimerosal induced hypersensitivity, myelodysplastic syndrome and pancytopenia

A case of hypersensitivity reaction, myelodysplastic syndrome and pancytopenia, which developed after an administration of thimerosal-containing tetanus vaccine, is presented and discussed.

Seropositivity rates of HBsAg, anti-HCV, anti-HIV and VDRL in blood donors in Eastern Turkey

Infections caused by hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency viruses (HIV) remain the leading most important health problems worldwide. Screening tests such as HBsAg, anti-HCV, anti-HIV and VDRL are mandatory tests to look at before transfusion of blood or blood components. In this study, donors who applied to our Blood Center in a nine-year period were retrospectively evaluated with respect to HBsAg, anti-HCV, anti-HIV and syphilis seroprevalence. HBsAg, anti-HCV and anti-HIV were examined by microparticle ELISA system, and syphilis antibodies were screened by a syphilis test device. Of the total 39,002 individuals, 16,601 (42%) were females and 22,401 (58%) were males. HBsAg positivity was found in 2.55%, anti-HCV in 0.17%, anti-HIV in 0.036%, and VDRL in 0.057% of overall donors. As a result, HBsAg, anti-HCV, anti-HIV and VDRL seropositivity rates in donors living in our region were found lower than those in many regions of Turkey. Nevertheless, because there is no screening method to reduce the risk resulting from transfusion to zero, it appears that it is essential to adopt strict criteria in the selection of donors and to avoid unnecessary transfusion.

Comparison of intramuscular and intradermal applications of hepatitis B vaccine in hemodialysis patients

This study compared the application of intramuscular recombinant hepatitis B vaccine in hemodialysis patients with the application of accelerated intradermal recombinant hepatitis B vaccine, which can be applied with one-tenth of the standard dose. Sixty seronegative patients for hepatitis B were randomly separated into two groups. Twenty mug of the recombinant hepatitis B vaccine was intramuscularly applied at 0-, 1-, 2-, and 6-month intervals to the first group (32 cases). One more dose was applied at month 12 to those whose anti-HBs titers remained below 100 mIU/mL at month 7. The same vaccine was intradermally applied at 2 microg dose six times with one-month intervals to the second group (28 cases). Vaccine applications were continued in those whose anti-HBs titers remained below 100 mIU/mL at month 7 until antibody titers reached above this value or until the dose number became 12. Measurements of antibody titers were repeated at month 13 in both groups. As a result, in the vaccination of hemodialysis patients against hepatitis B, the accelerated ID application of hepatitis B vaccine with a dose reduced to one-tenth is more cost-effective than the standard dose vaccination schedules. Especially for hemodialysis patients, the time has come for routine application of ID hepatitis B vaccine as an alternative vaccination method.

[A case of brucellosis presenting as high titer negative result by standard tube agglutination test]

Since prozone is a well known phenomenon in the serologic diagnosis of Brucella infections, it is necessary to prepare higher serum dilutions in the standard tube agglutination (STA) test for the brucellosis suspected patients. However, due to limited economical support, the serum dilutions generally last at 1/320-1/640 titers in some laboratories in Turkey. In this report, a brucellosis case whose STA test was found negative until the titer of 1/1280, has been presented. A 36-year-old female was admitted to our hospital with the complaints of fever, sweating, fatigue, generalized arthralgia and weight loss, lasting for 45 days. Hepatosplenomegaly was detected in the physical examination, and laboratory tests yielded anemia, leucopenia, elevated erythrocyte sedimentation rate and high C-reactive protein levels. Although brucellosis was suspected, Brucella STA test was found negative at 1/640 titer. On the sixth day of admission, Brucella melitensis was isolated from her blood culture. Since a positive result at 1/40 titer was detected in Brucella STA test with the use of Coombs antiserum, the patient's serum was retested at higher dilutions than 1/640, and positive result was obtained starting from 1/1280 dilution and extended to 1/5120 titer. The patient was treated with rifampin and doxycyline and discharged with complete cure. In conclusion, in countries endemic for brucellosis, STA test should be performed at 1/1280 or higher titrations in suspected patients especially in the presence of negative culture results, for the prevention of false negative results due to prozone phenomenon.

Avian influenza A (H5N1) infection in eastern Turkey in 2006

BACKGROUND

An outbreak of highly pathogenic avian influenza A (H5N1) that had previously been detected throughout Asia, with major economic and health repercussions, extended to eastern Turkey in late December 2005 and early January 2006.

METHODS

We documented the epidemiologic, clinical, and radiologic features of all cases of confirmed H5N1 virus infection in patients who were admitted to Yuzuncu Yil University Hospital in Van, Turkey, between December 31, 2005, and January 10, 2006.

RESULTS

H5N1 virus infection was diagnosed in eight patients. The patients were 5 to 15 years of age, and all eight had a history of close contact with diseased or dead chickens. The mean (+/-SD) time between exposure and the onset of illness was 5.0+/-1.3 days. All the patients had fever, and seven had clinical and radiologic evidence of pneumonia at presentation; four patients died. Results of enzyme-linked immunosorbent assay and rapid influenza tests were negative in all patients, and the diagnosis was made by means of a polymerase-chain-reaction assay.

CONCLUSIONS

H5N1, which causes a spectrum of illnesses in humans, including severe and fatal respiratory disease, can be difficult to diagnose.

Chronic hepatitis delta virus infection in Van region of eastern Turkey

BACKGROUND/AIMS

Hepatitis delta virus infection is an important cause of liver morbidity and mortality worldwide. In Eastern Turkey, hepatitis B virus infection is the major cause of chronic liver diseases. We aimed to research the role of hepatitis delta virus infection in chronic liver diseases related to hepatitis B virus infection in the Van region of Eastern Turkey.

METHODS

Serological markers of hepatitis B virus and hepatitis delta virus infection [HBsAg, HbeAg, Anti-HBe and Anti- hepatitis delta virus total (IgM+IgG)] were determined by ELISA test in patients with chronic hepatitis and cirrhosis. Serum hepatitis B virus DNA was determined by polymerase chain reaction (PCR) method in chronic hepatitis B patients.

RESULTS

Hepatitis delta virus infection was detected in 5% (7/138) of asymptomatic hepatitis B virus carriers, in 16% (24/148) of chronic hepatitis B patients and in 45% (34/75) of cirrhotic hepatitis B virus patients. hepatitis delta virus infection showed a three-fold increase in chronic hepatitis (p<0.01) and nine-fold increase in cirrhosis (p<0.001) compared to hepatitis delta virus carriers. Also, it was three times more frequent in cirrhosis (p<0.001) compared to chronic hepatitis. Chronic hepatitis delta virus infection was equally distributed between sexes in patients with chronic hepatitis B virus infection, whereas chronic hepatitis B virus infection alone was three times more frequent in males (p<0.001). Mean ages of hepatitis delta virus carriers, chronic hepatitis D and hepatitis delta virus cirrhosis patients were 30.7+/-8 (14-65), 36+/-13 (19-70) and 44 +/-16 (25-55), respectively.

CONCLUSIONS

The higher prevalence of hepatitis delta virus infection in more severe form of hepatitis B virus infection suggests that hepatitis delta virus infection increases the severity of chronic hepatitis B virus infection in the Van region. hepatitis delta virus infection remains a second major cause of chronic liver diseases in Eastern Turkey in spite of its decreasing prevalence in Western countries and in Western Turkey.

Cutaneous manifestations of anthrax in Eastern Anatolia: a review of 39 cases

Anthrax is essentially a disease of grazing herbivorous animals. The most common form of the disease is cutaneous anthrax, which accounts for 95% of all cases. We report here 39 cutaneous anthrax cases in humans that were seen in Eastern Anatolia over a six-year period. The clinical presentation was malignant edema in 16 of the cases (41%) and malignant pustule in 23 (59%). A secondary bacterial infection was present in 13 patients (33.3%) in the vicinity of the lesions. The agent was observed using Gram-stained smears in 25 patients (64%), and Bacillus anthracis was isolated from 15 patients (38.5%). All of the patients were treated with penicillin G or penicillin procaine, except one patient who had a penicillin allergy. One patient with cervical edema (2.5%) died as a result of laryngeal edema and sepsis syndrome. In conclusion, we found that the appearance of the skin lesion of cutaneous anthrax may vary, and this fact, combined with the rarity of this disease, which contributes to a general lack of experience among medical personnel, may make diagnosis difficult in nonagricultural settings

Use of the Brucella IgM and IgG flow assays in the serodiagnosis of human brucellosis in an area endemic for brucellosis

The clinical utility of two complementary tests for brucellosis, the Brucella IgM and IgG flow assays, was evaluated in a hospital in eastern Turkey. The results show that the flow assays are convenient diagnostic tests for use in endemic areas. A positive result in the flow assays was obtained in 91% and 97% of the admission sera from adult and pediatric patients with brucellosis, respectively, and the sensitivity at admission was 100% for culture-confirmed brucellosis. The assay system performed equally well in diagnosing patients at different stages of illness including patients with acute, subacute, or chronic disease and with relapse. The results of the flow assays correlated well with those of a serum agglutination test at a cut-off > or =1:160. The agreement was 92%. Application of the flow assays on serum samples collected during a village survey for brucellosis after an outbreak demonstrated their diagnostic potential as field tests.

Report of five children with Guillain-Barré syndrome following a nationwide oral polio vaccine campaign in Turkey

Five children with Guillain-Barré syndrome (GBS), following a national oral polio vaccination campaign to eradicate disease, are reported. Clinical examination, cerebrospinal fluid and electromyographic findings conformed to the classical description of GBS. Four of them received therapeutic dose of intravenous immunoglobulin G. Two children succumbed to the disease. It was observed that the number of cases of GBS in children increased during the period of the oral polio vaccination campaign in Turkey, suggesting a causal relationship.

Food-borne botulism cases in Van region in eastern Turkey: importance of electromyography in the diagnosis

OBJECTIVES

Food-borne botulism is an acute form of poisoning that results from ingestion of a toxin produced by Clostridium botulinum. Botulism toxin causes its major effect by blocking neuromuscular transmission in autonomic and motor nerve terminals.

METHODS

In this study, we present the features of eleven cases of food-borne botulism admitted to our hospital in 2001. All of the cases were caused by home-prepared foods; green beans. In these cases, the main symptoms and signs were generalized muscular weakness, dry mouth, dysphagia, disponea and diplopia. Electrophysiological studies were performed on four patients.

RESULTS

Motor conduction studies showed that compound muscle action potentials were decreased with normal latencies and conduction velocities. The needle electromyography showed signs of denervation potentials like fibrillation and positive waves in four patients. Repetitive nerve stimulation with high frequency (20 Hz) induced an increment close to 100% in the amplitudes in 2 of 4 patients.

CONCLUSION

Although toxin could not be detected in the patients, the electromyographic findings supported our diagnosis. We concluded that electromyography has an important role in diagnosis of botulism, especially in the condition that serologic tests are negative or cannot be performed.

The Effect of Levamisole Combined with the Classical Treatment in Chronic Brucellosis

Levamisole is an immunopotenciator drug which is used as an antihelmintic drug as well as very effective remedy on cellular immunity compared with humoral immunity. A total 71 patients (37 men, 34 women) who referred to our department between March 1997 and December 2001, with a history of the disease for about 1 year, were diagnosed as having chronic brucellosis through those tests brucella serum agglutination test (SAT), SAT with Coombs and SAT with 2-mercaptoethanol. The patients were randomly divided into levamisole group (36 patients) and control group (35 patients). All patients were given rifampicin 600 mg/day + doxycycline 200 mg/day for 6 weeks as a standard classical combined therapy for brucellosis. In the levamisole group, oral levamisole 80 mg every other day for 6 weeks was added to the treatment. There was a statistically significant difference between two groups, in complaints of arthralgia, fatigue and sweats before and 6 months after treatment, as well as in erythrocyte sedimentation rate and C-reactive protein elevations and lymphomonocytosis finding. While it was provided both clinical and serological improvement in all patients in the levamisole group; 11 patients in the control group did not improve both clinically and in view of specific and nonspecific laboratory findings and a recurrence occurred in one case, in this group. In conclusion, levamisole added to classical antibiotic therapy in treatment of chronic brucellosis was found quite efficient in all patients in providing adequate clinical and laboratory response in comparison to classical antibiotic therapy alone.

The treatment duration of acute maxillary sinusitis: how long should it be? A nasal smear controlled study

The aim of this study was to determine the most appropriate duration of treatment in acute maxillary sinusitis. The study was performed prospectively on 40 adult patients with acute maxillary sinusitis diagnosed by sinus puncture. Patients were randomized as to several treatment periods and treated by various antibiotics according to culture-sensitivity results. Patients in group 1 received treatment for 7 days; groups 2, 3, and 4 received 14, 21, and 28 days, respectively. The patients were followed up with nasal smear findings on certain intervals during the 56-day follow-up period. Statistically significant differences were found beginning from the 21st day between group 1 and the other groups. However, there were no statistical differences among groups 2, 3 and 4. These findings show that the most appropriate duration of treatment in acute maxillary sinusitis should be at least 14 days according to nasal smear results.

A brucellosis case with ascites, hearing loss and pancytopenia

To date there has been no association of ascites, hearing loss and pancytopenia in brucellosis in the literature. A 25-year-old female patient was hospitalized with fever, hearing loss, ascites and pancytopenia. Cultures from bone marrow and ascites yielded growth of Brucella melitensis and Brucella standard tube agglutination was found to be positive at a titer of 1/1280. The patient completely recovered by the sixth week following combined antibacterial treatment of ciprofloxacin, rifampin and doxychline.

Cutaneous findings encountered in brucellosis and review of the literature

BACKGROUND

Human brucellosis is an infectious disease produced by Brucella species: small, coccoid or rod-like, aerobic, Gram-negative bacteria. The infection is common in developing countries, and can also affect the skin. Its prevalence is high in our region of Turkey, where stockbreeding is one of the main economic sources, compared with the industrially developed areas of Turkey, and dermatologic complaints due to brucellosis are fairly common.

MATERIALS AND METHODS

One hundred and three patients with serologically and clinically confirmed brucellosis were studied in order to investigate the prevalence of cutaneous findings and their variability in brucellosis. Fifty-two (50.49%) were males and 51 (49.51%) were females with an age range of 4-70 years (mean, 30.45 +/- 15.08 years).

RESULTS

Of these patients, 14 (13.59%) had cutaneous findings probably related to brucellosis. These findings were more frequent in females (11 cases) than males, and most of the females (eight cases) were housewives; three were students. Urticaria-like papules and plaques were the most common findings; they were seen in six (35.3%) patients. One case had livedo reticularis and another palmar erythema, which have not been reported previously. No relationship was observed between the serologic values and the cutaneous findings.

CONCLUSIONS

Cutaneous findings in our cases were more prevalent than in other reported studies. It is important to emphasize that cutaneous lesions are not specific to brucellosis and may be seen in a variety of other dermatologic diseases caused by many agents; therefore, these agents should be kept in mind in the differential diagnosis.

The effect of triclabendazole (Fasinex) in children with fasciolosis

Three children infected with Fasciola hepatica (FH) were treated with triclabendazole (TCZ; Fasinex). In the first two patients, firstly, albendazole (Andazole) was administered, but did not stop the excretion of FH eggs. To these two patients, TCZ was administered in a single oral dose of 10 mg/kg postprandially. Two month later, very few eggs were found in stool samples. So, the same dose of triclabendazole was secondly given to the patients. After this therapy. FH eggs have not been found in the repeated stool examinations for a follow up of one year. To the third patient, TCZ was administered in a single oral dose of 10 mg/kg together with food. This patient has remained free of complaints and stool samples were free from FH eggs for two months. In conclusion, TCZ may be used as a treatment of choice for human fasciolosis both in adults, and children.

Central nervous system brucellosis: presentation, diagnosis and treatment

Although neurological symptoms in brucellosis are frequent, central nervous system (CNS) involvement is uncommon. Five patients with neurobrucellosis are presented. Three patients presented with meningoencephalitis, one with polyradiculoneuritis and one with myelitis and an eighth nerve palsy. All patients had lymphocytic pleocytosis, low glucose and elevated levels of protein in the cerebrospinal fluid (CSF). Gamma-globulin and IgG values in the CSF were also increased. Results of agglutination tests for Brucella in serum and CSF were positive for all patients, although titres were less in the CSF. Brucella melitensis was cultured from two patients. Treatment included concurrent administration of three of the following drugs: doxycycline, rifampicin, streptomycin, co-trimoxazole, ceftriaxone or ciprofloxacin. The three patients with meningoencephalitis fully recovered; the other two patients were left with minor disability.

Hematological manifestations in brucellosis cases in Turkey

The hematological findings of 233 patients with brucellosis are presented and the possible pathologies discussed. Anemia was present in 128 patients (55%), leukopenia in 49 (21%) and thrombocytopenia in 59 (26%). Bone marrow aspirates of 18 patients (8%) with pancytopenia were examined. The bone marrow was hypercellular in 15 and normocellular in 3 patients. Granulomatous lesions were detected in 12 cases (67%), and slight to moderate cytophagocytosis of erythrocytes, granulocytes and platelets existed in all patients. Blood cell counts reverted to normal within 2-3 weeks of initiating chemotherapy with recovery from the disease.