The spectrum of diseases causing fever of unknown origin in Turkey: a multicenter study.

OBJECTIVE: The purpose of this trial was to determine the spectrum of diseases with fever of unknown origin (FUO) in Turkey. METHODS: A prospective multicenter study of 154 patients with FUO in twelve Turkish tertiary-care hospitals was conducted. RESULTS: The mean age of the patients was 42+/-17 years (range 17-75). Fifty-three (34.4%) had infectious diseases (ID), 47 (30.5%) had non-infectious inflammatory diseases (NIID), 22 (14.3%) had malignant diseases (MD), and eight (5.2%) had miscellaneous diseases (Mi). In 24 (15.6%) of the cases, the reason for high fever could not be determined despite intensive efforts. The most common ID etiologies were tuberculosis (13.6%) and cytomegalovirus (CMV) infection (3.2%). Adult Still's disease was the most common NIID (13.6%) and hematological malignancy was the most common MD (7.8%). In patients with NIID, the mean duration of reaching a definite diagnosis (37+/-23 days) was significantly longer compared to the patients with ID (25+/-12 days) (p=0.007). In patients with MD, the mean duration of fever (51+/-35 days) was longer compared to patients with ID (37+/-38 days) (p=0.052). CONCLUSIONS: Although infection remains the most common cause of FUO, with the highest percentage for tuberculosis, non-infectious etiologies seem to have increased when compared with previous studies.

Pathogens isolated from deep soft tissue and bone in patients with diabetic foot infections.

BACKGROUND: We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. It is widely believed that soft-tissue cultures are adequate in the determination of causative bacteria in patients with diabetic foot osteomyelitis. The culture results of specimens taken concurrently from soft-tissue and bone infections show that the former does not predict the latter with sufficient reliability. We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. METHODS: Forty-five patients with diabetic foot infections were enrolled in the study. Patients had to have clinically suspected foot lesions of grade 3 or higher on the Wagner classification system. In patients with clinically suspected osteomyelitis, magnetic resonance imaging, scintigraphy, or histopathologic examination were performed. Bone and deep soft tissue specimens were obtained from all patients by open surgical procedures under aseptic conditions during debridement or amputation. The specimens were compared only with the other specimens taken from the same patients. RESULTS: The results of bone and soft-tissue cultures were identical in 49% (n = 22) of cases. In 11% (n = 5) of cases there were no common pathogens. In 29% (n = 13) of cases there were more pathogens in the soft-tissue specimens; these microorganisms included microbes isolated from bone cultures. In four patients (9%) with culture-positive soft-tissue specimens, bone culture specimens remained sterile. In one patient (2%) with culture-positive bone specimen, soft-tissue specimen remained sterile. CONCLUSION: Culture specimens should be obtained from both the bone and the overlying deep soft tissue in patients with suspected osteomyelitis whose clinical conditions are suitable. The decision to administer antibiotic therapy should depend on these results.

[Nosocomial respiratory syncytial virus infections in three cases in a bone marrow transplantation unit]. / Kemik iligi nakli ünitesinde yatan üç olguda nozokomiyal solunum sinsityal virus enfeksiyonu.

Here we report the spread of respiratory syncytial virus (RSV) infection among three patients, who were hospitalized in an adult hematopoetic stem cell transplantation (HSCT) unit because of hematologic diseases, and effects of RSV infection on post-transplant outcome. The patients were placed into reverse isolation for administration of preparative regimens (high dose chemotherapy) in HSCT unit with high-energy particulate air (HEPA)-filtered single rooms. First case was a 62 years-old man with advanced multiple myeloma, which was refractory to multiple line treatment with high dose steroid including regimens and with secondary acute myelogenous leukaemia (AML); second case was a 45 years-old male patient with multiple myeloma, who had undergone autologous HSCT following high dose chemotherapy; third case was a 52 years-old man with AML that was refractory to multiple line treatment and had undergone allogeneic HSCT from a HLA-matched unrelated donor. Nasopharyngeal aspirate samples were collected from the patients in order to search for RSV positivity. RSV was investigated by in-house nested polymerase chain reaction (PCR) in the first patient and by direct antigen detection method (Monofluoscreen RSV-Biorad, France) in the others. First case had clinical picture of RSV infection just on the HSCT day when high dose chemotherapy has already been given. As RSV-RNA analysis yielded positive result, peroral ribavirin was initiated. Engraftment did not occur in this patient. He developed severe respiratory failure which necessitated mechanical ventilatory support, however, he has succumbed. After the detection of RSV positive index case, weekly screening of RSV in other five patients in the same unit had been performed. Following the first case, after nine and 17 days, respectively, RSV positivity was detected in two more patients. While clinical signs and symptoms of RSV infection developed in second case, third case remained asymptomatic. Both of the following patients had received ribavirin very early at first RSV positivity and recovered from RSV infection. Engraftment did not occur in the last patient who had undergone allogeneic HSCT from a HLA-matched unrelated donor and a second HSCT was performed. As a result, in HSCT patients, early diagnosis of RSV infection by PCR analysis may provide support to postpone immunosupressive treatment and help assesment of the management.

Haemophagocytosis in a patient with Crimean Congo haemorrhagic fever.

Crimean-Congo haemorrhagic fever (CCHF) is a severe disease with a case fatality of 2.8 to 80 %. A patient dwelling in an endemic region for CCHF was admitted with fever preceding bleeding diathesis and pancytopenia. Despite no history of tick exposure, CCHF was highly suspected. With an oral ribavirin therapy, clinical and laboratory improvements were obtained. The diagnosis was confirmed by detection of IgM antibody to CCHF virus and positive RT-PCR. Although the main pathogenesis of CCHF infection is not elucidated yet, haemophagocytosis, a symptom rarely reported in viral haemorrhagic fevers, was observed in this case. Haemophagocytosis is suggested to have a role in the development of pancytopenia in CCHF, the mechanism of which still needs to be investigated, probably with cytokine studies. Together with clinical symptoms and patient history, haemophagocytosis may be an indicator for CCHF.

Genetic subtypes of human immunodeficiency virus type 1 (HIV-1) in Istanbul, Turkey.

BACKGROUND: Epidemiological surveillance of HIV-1 subtypes is an important and ongoing element of preparation for global antiviral interventions. OBJECTIVE: To assess the molecular epidemiology of HIV-1 in Istanbul, Turkey. STUDY DESIGN: 27 HIV/AIDS patients were investigated. Data on age, sex, country of birth, and HIV acquisition route were collected. Following amplification with PCR the sequences of the gp41 region of the env gene were determined using a 310 DNA sequencer (ABI prism, Foster City, USA) and phylogenetically analyzed. RESULTS: Among the 27 patients (26 adults and 1 infant), 22 were male, born in Turkey, and 20 infected through heterosexual contact. Two patients acquired the virus through blood and/or blood transfusion and one infant by vertical transmission. The distribution of the subtypes was as follows: four were subtype A, 19 subtype B, one subtype C, one subtype D, and two subtype F1. According to our results, although the B subtype is still predominant, non-B subtypes are also present, even though the number of registered HIV/AIDS patients is low. CONCLUSION: These are the first subtyped HIV-1 strains in Turkey where a low level of HIV prevalence has been observed since the first reported case in 1985. These findings and Turkey's specific geographic localization indicate the need for a nationwide surveillance to detect all subtypes including the new recombinant ones.

Ventilator-associated pneumonia in surgical emergency intensive care unit.

OBJECTIVE: To investigate the incidence, risk factors and the etiology of ventilator-associated pneumonia (VAP) in surgical emergency intensive care unit (ICU) patients. METHODS: We conducted this prospective cohort study in the surgical emergency ICU of Istanbul Medical Faculty between December 1999 and May 2001. We included 100 mechanically ventilated patients in this study. We diagnosed VAP according to the current diagnostic criteria. We identified the etiology of VAP cases by both quantitative cultures of endotracheal aspiration and blood cultures. To analyze the predisposing factors for the development of VAP, we recorded the following variables: age, gender, acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA) score, serum albumin level, duration of mechanical ventilation (MV) prior to the development of VAP, and underlying diseases. RESULTS: We determined the VAP incidence rate as 28%. We found the APACHE II score and the duration of MV to be statistically significant variables for the development of VAP. There were no significant differences regarding age, gender, GCS, SOFA score, albumin level, or underlying diseases for the development of VAP. The isolated bacteria among VAP cases were as follows: Staphylococcus aureus (n=12, 43%), Acinetobacter spp. (n=6, 21%), coagulase-negative Staphylococci (n=4, 15%), Pseudomonas aeruginosa (n=3, 10.7%) and Klebsiella pneumoniae (n=3, 10.7%). CONCLUSION: Ventilator-associated pneumonia is a common infection, and certain interventions might affect the incidence of VAP. The ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP, and modifying patient care to minimize the risk of VAP.

Central venous catheter related infections: risk factors and the effect of glycopeptide antibiotics.

BACKGROUND: We undertook a prospective study of all new central venous catheters inserted into patients in the intensive care units, in order to identify the risk factors and to determine the effect of glycopeptide antibiotics on catheter - related infections. METHODS: During the study period 300 patients with central venous catheters were prospectively studied. The catheters used were nontunneled, noncuffed, triple lumen and made of polyurethane material. Catheters were cultured by semiquantitative method and blood cultures done when indicated. Data were obtained on patient age, gender, unit, primary diagnosis on admission, catheter insertion site, duration of catheterization, whether it was the first or a subsequent catheter and glycopeptide antibiotic usage. RESULTS: Ninety-one (30.3%) of the catheters were colonized and infection was found with 50 (16.7%) catheters. Infection was diagnosed with higher rate in catheters inserted via jugular vein in comparison with subclavian vein (95% CI: 1.32-4.81, p = 0.005). The incidence of infection was higher in catheters which were kept in place for more than seven days (95% CI 1.05-3.87, p = 0.03). The incidence of infection was lower in patients who were using glycopeptide antibiotic during catheterization (95% CI: 1.49-5.51, p = 0.005). The rate of infection with Gram positive cocci was significantly lower in glycopeptide antibiotic using patients (p = 0.01). The most commonly isolated organism was Staphylococcus aureus (n = 52, 37.1%). CONCLUSION: Duration of catheterization and catheter insertion site were independent risk factors for catheter related infection. Use of glycopeptide antibiotic during catheterization seems to have protective effect against catheter related infection.

Acute prostatitis as an uncommon presentation of brucellosis.

The present report concerns a 46-year-old man who presented with acute prostatitis due to Brucella melitensis infection. He was first treated with doxycycline and ciprofloxacin, but after 3 months he was admitted again with the same diagnosis. The relapse was probably related to ciprofloxacin use, or the length of treatment not being sufficient. The patient was successfully treated with a combination of doxycycline and rifampin for 3 months. In conclusion, prostatitis due to Brucella, such as spondylitis, meningoencephalitis and endocarditis, should be treated for longer courses.

Risk factors for mortality of nosocomial bacteraemia in intensive care units.

OBJECTIVE: The aim of this study was to follow critically ill patients prospectively in intensive care units (ICUs) to determine risk factors for mortality and outcome associated with nosocomial bacteraemia (NB). SUBJECTS AND METHODS: A case-control study of 176 patients was conducted to identify the risk factors for mortality of NB in ICU patients. The study was performed in emergency, surgical and general surgical ICUs with 23 beds during a 15-month period. A total of 1,450 patients were admitted to the ICUs during the study period. The USA Center for Disease Control and Prevention definitions were used to diagnose nosocomial infections. Nosocomial bacteraemia was defined as the isolation of one or more organisms from blood cultures taken at least 48 h after admission, which were not related to a problem present on admission. An assessment of whether the isolated organisms represented true bacteraemia rather than contamination was made by clinical or laboratory evidence of infection. RESULTS: A total of 214 bacteraemia episodes were found in the 176 patients (64 female, 112 male; 51.3 +/- 21.3 years old), 90 of whom died and 86 survived. The bacteraemia rate was 12.1%. The most common etiological agents of bacteraemia were Klebsiella pneumoniae: 46 (21.5%), methicillin-resistant Staphylococcus aureus: 46 (21.5%), Pseudomonas aeruginosa: 32 (14.9%), and Escherichia coli: 20 (9.3%). Multivariate analysis showed that the requirement of mechanical ventilation for more than 7 days (p < 0.001), total parenteral nutrition (p = 0.034), inotropic drug (p < 0.001), and increased creatinine level (p = 0.034) were independent risk factors for mortality of NB in ICUs. CONCLUSIONS: Nosocomial infections caused by Gram-negative bacteria continue to be one of the major sources of morbidity and mortality.

Neisseria meningitidis with decreased susceptibility to penicillin in Istanbul, Turkey.

This study was conducted to estimate the rate of decreased susceptibility to penicillin (MIC > 0.06-1 microg/ml) in Neisseria meningitidis isolates in Istanbul, Turkey. A total of 30 isolates collected during a 1-y period from patients with meningitis and from nasopharyngeal carriers were tested for penicillin and cefotaxime susceptibility using the E-test. Two out of 12 (17%) clinical isolates and 11/18 (61%) nasopharyngeal isolates showed decreased susceptibility to penicillin with MICs in the range 0.094-1.0 microg/ml, giving an overall resistance of 43% (n = 13). These data show that continued surveillance of trends in antimicrobial susceptibility of N. meningitidis is important for detecting the emergence of N. meningitidis strains with MICs > 1 microg/ml which may pose serious therapeutic problems.

Extrapulmonary tuberculosis in immunocompetent adults.

Tuberculosis continues to be a significant cause of morbidity and mortality. Although tuberculosis usually attacks the lungs, other organs can also be affected, leading to extrapulmonary tuberculosis (EPT) or disseminated tuberculosis. This study retrospectively analysed the incidence, clinical sites and risk factors for EPT in 252 patients with EPT between 1 January 1991 and 30 June 2003. EPT was defined as clinical, laboratory, imaging, and/or histopathological evidence of mycobacterial infection in a site other than hilar lymph nodes or lung parenchyma. In our study group, tuberculous lymphadenitis (36.5%) was found to be the most common clinical presentation of EPT. 119 (47.2%) patients developed the severe form of EPT, according to the WHO report, and 133 (52.8%) patients developed the less severe form. A case history of pulmonary tuberculosis was found to be a risk factor for the development of EPT (p <0.05). The study showed that EPT is still a public health problem. These findings suggested that pulmonary tuberculosis may play a critical role in the development of EPT. 12-month therapy may be chosen in patients with EPT considering acceptable adverse effects without relapses.