[A rare case of endocarditis due to Moraxella catarrhalis in an immunocompetent patient]

Moraxella catarrhalis is a gram-negative, catalase and oxidase positive diplococcus. While it causes otitis media, sinusitis, bronchitis and conjunctivitis in children and adults, it has a tendency to cause lower respiratory tract infections in older ages. More severe clinical pictures with the range of sepsis to endocarditis are also seen in immunocompromised patients. In this report, a case of M. catarrhalis endocarditis in an immunocompetent host who needed valve replacement has been presented. Forty three years old female patient was admitted to our hospital with the complaints of fever, nausea, night sweating and arthralgia for 20 days. Physical examination revealed systolic murmurs on the apex, and vegetation on the atrial surface of mitral valve was detected by transthoracic echocardiography. Intravenous (IV) ampicillin (4 x 3 g/day) and gentamicin (3 x 80 mg/day) treatment was started empirically with prediagnosis of infective endocarditis. The treatment was modified to IV ceftriaxone (1 x 2 g/day) and gentamicin (3 x 80 mg/day) due to the reporting of gram-negative bacilli in blood culture (BacT/ALERT 3D, bioMérieux, France) on the next day. Gram-negative cocobacilli/diplococci were detected with Gram stain on the smear prepared from the blood culture bottle. Simultaneous subcultures to blood agar and eosin methylene blue agar yielded white colored, S-type, non-hemolytic colonies on only blood agar. Catalase and oxidase tests were positive, while beta-lactamase activity was negative. The isolate was identified as M. catarrhalis by using API NH (bioMérieux, France) identification strips. M. catarrhalis was isolated from five different blood culture specimens of the patient. The focus for bacteremia could not be detected. The patient underwent mitral valve replacement operation as an emergency since the vegetation exhibited rapid growth on the fifth day of medical treatment. Antibacterial therapy was completed for 6 weeks. Control echocardiography revealed that artificial mitral valve was open and functional, thus the patient recovered completely without sequela. In conclusion, M. catarrhalis should be considered as a possible cause of infective endocarditis even in immunocompetent patients.

[Community-acquired Pseudomonas stutzeri meningitis in an immunocompetent patient]

Pseudomonas stutzeri which is an aerobic, non-fermentative gram-negative bacillus frequently found in soil, water and hospital environment, rarely leads to serious community-acquired infections. In this report a case of community-acquired meningitis due to P. stutzeri was presented. A 73-years-old male patient was admitted to the emergency department with the complaints of nausea, vomiting, headache, dizziness, difficulties in walking and speaking and loss of consciousness. There was no history of an underlying disease or immunosuppression. Physical examination revealed nuchal rigidity, however, Kernig and Brudzinski signs were negative. The cerebrospinal fluid (CSF) analysis revealed 0.4 mg/dl glucose (simultaneous blood glucose 145 mg/dl), and 618 mg/dl protein and 640 leucocyte/mm3 (90% PMNL). No bacteria were detected in Gram stained and Ehrlich-Ziehl-Neelsen stained CSF smears. Upon the diagnosis of acute bacterial meningitis, treatment with ceftriaxone and ampicillin was initiated, however, the patient died after 16 hours of hospitalization. CSF culture yielded the growth of gram-negative oxidase-positive bacteria and the isolate was identified as P. stutzeri by Vitek-2 Compact system (bioMerieux, France). The isolate was found to be sensitive to piperacillin/tazobactam, amikacin, gentamycin, ceftazidime, cefepime, ciprofloxacin, imipenem and meropenem. Since the patient was lost due to acute respiratory and cardiac failure, it was not possible to change the therapy to agent specific therapy. In conclusion, it should always be kept in mind that uncommon agents could lead to community-acquired meningitis in elderly patients and empirical treatment protocols might fail in such cases resulting in high morbidity and mortality.

[In vitro effect of reactive nitrogen and oxygen intermediates alone and in combination with some antibiotics against Brucella melitensis clinical isolates]

Brucella spp. replicate and survive in lympho-proliferative tissues and cells, thus effective treatment of brucellosis requires the combined and long term use of intracellularly active antibiotics. Elimination of the microorganism largely depends on the reactive oxygen and nitrogen intermediates released by activated macrophages. In this study we aimed to determine the in vitro activity of hydrogen peroxide (H2O2; reactive oxygen intermediate) and acidified sodium nitrite (ASN; reactive nitrogen intermediate) alone and in combination with rifampicin (RIF) and tetracycline (TET) against four clinical isolates of Brucella melitensis. Initially minimal inhibitory concentrations of RIF and TET were determined by microbroth dilution susceptibility test. The activity of 2 and 5 mM H2O2 and 3 and 6 mM ASN was tested against each isolate by direct colony count from the agar plates inoculated with bacterial suspensions treated with H2O2 or ASN. The last step in the assay was to determine the combined effectiveness of RIF and TET plus H2O2 and ASN. From each three rolls of assay apparatus samples were taken at 0., 1., 6. and 24. hours and inoculated on Brucella agar. The plates were incubated at 37 degrees C for 48 hours and colonies were counted. While RIF alone or in combination with H2O2 supressed the growth of bacteria even in the first hour, TET alone did not show any effect in 24 hours. However, in combination with reactive oxygen and nitrogen intermediates TET affected bacterial growth starting from six hours. In conclusion, further explanation of the interactions between antibiotics and the substances produced by the immune system of the host during the infections caused by intracellular pathogens, might have an important impact on the determination of the treatment protocols and the measures to prevent relapses.

[Intracranial aspergillosis in an immunocompetent patient]

Intracranial aspergillosis is a rare clinical picture, but the mortality rate is very high. In this report, an immunocompetent 43 years old male patient with mortal intracranial aspergillosis was presented. The patient has been admitted to Neurosurgery Clinics of our hospital with the complaints of weakness and walking difficulties. In the cranial tomography a brain mass was detected, and his medical history revealed that he had experienced an operation 18 months ago because of another intracranial tumour. After the operation his fever was high (39 degrees C), the leukocyte count, erythrocyte sedimentation rate and CRP values were increased, and purulent discharge was present in the operation site. As the pathological examination of the operation material have suggested aspergillosis, conventional amphotericin B treatment was started initially, but has changed to liposomal form 18 days later. Aspergillus fumigatus has been grown on the exudate culture collected from flap region. The levels of immunoglobulins and complement components of the patient were found normal. Since his next cranial magnetic resonance result indicated the presence of pansinusitis and destructive lesions in ethmoid sinuses, caspofungin was added to the therapy. The patient has reoperated since there was no clinical and laboratory progress at the 83rd day of amphotericin B, and 10th day of caspofungin therapy. Bacterial and fungal cultures of specimens collected during the second operation yielded negative results, however microabscesses and chronic inflammation focci were detected in histopathological examination. Fever and purulent discharge recurred in the patient after the second operation and visual defect has developed in his left eye. There was no bacterial or fungal growth in the discharge material, but direct microscopy have showed the presence of septate hyphae. The patient was discharged from the hospital by his family request with oral itraconazole treatment, however, he died one month later. Since no immunosuppressive status was detected in our patient, the transmission was thought to occur during the operation which he had experienced one and half year ago. In conclusion, the patients who experience neurosurgery should be followed-up carefully in terms of aspergillosis.

[A case of secondary syphilis with hepatitis]

Hepatitis is a rare clinical manifestation of syphilis. In this report a 50 years old male patient who was diagnosed as secondary syphilis presenting with hepatitis has been discussed. The patient was admitted to the hospital with high fever and skin rash, and his history revealed a suspected sexual contact. He indicated that he had been admitted to a health center eight months ago because of the presence of a penile wound, however VDRL (Venereal Disease Research Laboratory) test was negative at that time. Fever (39.5 degrees C), jaundice in skin and sclera, generalized macular and maculopapular skin rash including palms and soles, lymphadenopathy and hepatosplenomegaly were detected in physical examination. Laboratory tests yielded elevated erythrocyte sedimantation rate, high CRP levels and elevated liver enzyme levels, however viral hepatitis markers together with VDRL and TPHA (Treponema pallidum hemagglutination) tests were found negative. Ceftriaxone therapy was initiated because of the presence of high fever (40 degrees C) and 30 leukocyte/mm3 in urine, and the absence of bacteria in Gram staining of urine sample. However, the antibiotic therapy was discontinued since fever persisted. As the clinical signs and symptoms strongly indicated syphilis, the serological tests were repeated and VDRL positivity at 1/8 and TPHA positivity at 1/1280 titers were detected. Ceftriaxone therapy was restarted and continued for 14 days with complete cure. Since the spouse of the patient was also found VDRL and TPHA positive, she was treated with penicilin. The presentation of this case emphasized the importance of repeating the serological tests for syphilis since they might be negative in the early stages of infection. The case also indicates that syphilis should be considered in the differential diagnosis of hepatitis.

[Short communication: use of cefoxitin disc diffusion method for the detection of methicillin resistance in Staphylococcus aureus clinical isolates]

The aim of this study was to compare the cefoxitin disc diffusion method with oxacillin broth microdilution and agar screening methods for the detection of methicillin-resistant Staphylococcus aureus (MRSA). The presence of PBP2a in 94 S. aureus clinical isolates were screened by latex agglutination MRSA-Screen test (Oxoid Ltd, UK), and 64 (68%) of the strains were found positive. Cefoxitin disc diffusion method and oxacillin broth microdilution and agar screening methods were performed in the guidance of Clinical and Laboratory Standards Institute (CLSI) proposals. All of the 64 PBP2a positive isolates were found resistant, and 30 PBP2a negative isolates were detected as susceptible to oxacillin by both of the broth microdilution and agar screening methods. In cefoxitin disc diffusion method, zone diameters of 62 isolates were measured as 0-14 mm, while two isolates gave 15-17 mm and 30 isolates gave 220 mm zone diameters. According to the CLSI proposals, 64 isolates were accepted as oxacillin-resistant in view of their cefoxitin zone diameters. As a result, the sensitivity and specificity of cefoxitin disc diffusion method was detected as 100%, when comparing with both gold standard (PBP2a presence) method and oxacillin broth microdilution and agar screening methods, indicating that it is a reliable test to investigate oxacillin resistance of clinical S. aureus isolates in routine laboratories where molecular tests could not be performed due to economical reasons.

[Surveillance study of vancomycin resistant enterococci in pediatric haematology and oncology patients]

In this study, the prevalence and risk factors of fecal carriage of vancomycin resistant enterococci (VRE) among patients in Ondokuz Mayis University Pediatric Hematology and Oncology Clinics have been investigated. During two months, rectal swab samples were collected weekly from all of the patients hospitalized in Pediatric Hematology and Oncology Clinics, for the surveillance cultures. During the study a total of 85 rectal swabs were obtained from 34 patients who had been hospitalized in the inpatient clinic with 20 bed capacity. The number of samples obtained from the patients varied between 1-6 cultures. All of the patients (100%) had peripheral venous catheters and 27(79%) of patients had used antibiotics. All of the samples were inoculated onto 8 microg/ mL gentamicin containing blood agar media, and enterococci were identified by Gram staining, catalase test and at species level by VITEK 2 (bioMérieux, France) automated system. Vancomycin resistance was screened by using 6 microg/mL vancomycin containing brain-heart infusion agar according to CLSI guidelines. The vancomycin MIC values of the strains grown in this medium were determined by microdilution test proposed by CLSI. As a result, a total of 50 samples (59%) belonging to 24 patients yielded enterococci, and the species distribution was as follows; E. faecium (in 16 cases), E. faecalis (in 8 cases), E. casseliflavus (in 6 cases), E. avium (in 3 cases) and E. durans (in 1 case). In our study no vancomycin resistance nor VRE colonization was detected in the patients.

[Case report: a nosocomial infection caused by vancomycin resistant enterococcus]

Vancomycin resistant enterococcus (VRE) was recovered from the urine culture of a 61 years old female patient, who was being treated for sepsis, on the 15th day of hospitalization in Ondokuz Mayis University Hospital Infectious Disease Unit. The underlying diseases of this patient were chronic renal failure and diabetes mellitus. The patient died due to septic shock on the day of VRE isolation. Since this case was the first VRE infection in our hospital, a point prevalence study was planned. For this purpose, rectal swab samples collected from 10 patients from the same unit and 27 personnel who worked in the same unit, were screened for the presence of VRE. Nasal swabs and finger tip samples were also taken from the staff to determine if the transmission has occured in this way. As a result, a second VRE strain was isolated from another patient with chronic renal failure who was under treatment due to multiple pulmonary abscesses. Immediate isolation of this patient prevented a possible epidemic in this specific unit. In this report, the importance of VRE screening and isolation of the patients after the recovery of VRE has been emphasized.

[Evaluation of phenol ammonium sulfate sedimentation method for diagnosis of pulmonary tuberculosis]

In the study, the results of culture have been accepted as a gold standard and the specificity and sensitivity of phenol ammonium sulfate sedimentation method has been evaluated. When it is evaluated according to the results of culture, it has been found that the specificity and sensitivity of phenol ammonium sulfate sedimentation method is 90%, the specificity of the process which is made through the N-acetyl-L-cysteine NaOH method is 90% and the sensitivity of it is 85%. In conclusion, the phenol ammonium sulfate method seems to be as a secure method that can only be used in the laboratories in which microscopic studies are made.

[Meningitis due to Pseudomonas stutzeri: a case report]

Pseudomonas stutzeri is a saprophytic microorganism that rarely causes severe infections. In this report, a 28 days old male patient with meningomyelocele at birth was presented. The patient was admitted to the hospital with fever, and diagnosed as meningitis on the basis of physical examination and leukocytosis (blood: 16.380/mm3, cerebrospinal fluid (CSF): 130/mm3; 90% PMNL). Following diagnosis ceftriaxone therapy was started led to improvement in clinical and laboratory findings. However on the 20th day, the clinical signs and symptoms became worse, and the patient was diagnosed to develop a second meningitis attack by laboratory examination of CSF. P. stutzeri was isolated from the CSF culture, and the isolate was found to be resistant to ceftriaxone. Upon this result the therapy has changed to meropenem. On the 5th day of the therapy, the patient has slightly improved and he was discharged due to the wishes of his parents, however he died two days after discharge. This first case of P. stutzeri meningitis in neonates was presented to withdraw attention to this clinical entity.