[A Rickettsia case caused by Rickettsia conorii]. / Rickettsia conorii'nin neden oldugu riketsiyal enfeksiyon olgusu.

Rickettsia species are gram-negative intracellular, small pleomorphic coccobacilli in the Rickettsiaceae family. This genus is serologically and genotypically divided into four groups as spotted fever group, typhus group, Rickettsia belli and Rickettsia canadensis. Rickettsia conorii (R.conorii subsp. conorii) in the spotted fever group was reported to cause mediterranean spotted fever in Europe, especially in mediterranean countries including Turkey. The major vectors of Rickettsia species are ticks, and in some species fleas or mites. In this report a case with R.conorii infection was presented. A 46-year-old female patient, who had anorexia, fatigue, muscle aches, chills and high fever was admitted to a health institution. The patient was diagnosed as influenza. There was no regression in the patient's complaints with the recommended treatment. The patient was examined in our infectious diseases clinic and had several symptoms like severe muscle and joint pain with significant headache, and rashes at her body including hands and feet. The patient had a single eschar in the upper midline of the belly that matched tick biting and pink small maculopapular scars on the trunk, arms, legs, feet, and hands. Considering a Rickettsia pre-diagnosis, liquid electrolyte and doxycycline 2 x 100 mg oral treatment was started. On the third day of treatment, high fever, muscle and joint pain were decreased. On the fifth day, active skin lesions were started to fade. R.conorii IgM and IgG were negative in the first serum sample of the patient. In the biopsy sample taken from eschar tissue, Rickettsia spp. was detected as positive with rt-PCR. PCR was used by using the specific regions of the genetically specific gltA and ompA genes in the biopsy specimens and then the PCR products were determined by DNA sequence analysis. The DNA sequence results were compA red with Genbank data and determined that the gltA sequence was 99%, similar to R.conorii with accession number JN182786 and the ompA sequence was 99%, similar to R.conorii with accession number KR401144. When the phylogenetic tree was created, it was observed that the etiological agent was R.conorii. A week after the treatment, in the second serum sample R.conorii IFA IgM 1/192 titer and IgG 1/320 titer were detected as positive. In this case report, we have presented a Rickettsia case, clinically diagnosed as Rickettsia, serologically negative in the acute phase, PCR positive, with post-treatment seroconversion and etiologic agent determined as R.conorii.

[Evaluation of a newly-developed ready-to-use commercial PCR kit for the molecular diagnosis of Francisella tularensis]. / Francisella tularensis'in moleküler tanisinda yeni gelistirilen kullanima hazir ticari PCR kitinin etkinliginin degerlendirilmesi.

Tularemia is a rare zoonotic infection, however, considerations of tularemia as a biological weapon and several recent major epidemics have caused renewed interest in this disease. Laboratory diagnosis of tularemia is done in the presence of appropriate epidemiological data, by the demonstration of specific antibodies in the serum samples obtained with 1-2 week intervals following the development of symptoms. It is an a posteriori analysis with limited use for prompt diagnosis of the patient during the early symptomatic phase and deliberate release of biological agents. Limitations in both culture and serology have led to substantial research in the development of new diagnostic techniques. Several PCR methods for tularemia have been developed, both for conventional and real-time polymerase chain reaction (rtPCR). However, PCR methods are hard to be deployed in remote endemic areas that lack sufficient infrastructure. Recently a "Toolbox" which includes all instruments, equipments and solutions [DNA4U® Bacteria Genomic DNA Isolation Kit, CubeCycler® (Personal Thermal Cycler), PCR4U® Bioterrorism Agents Detection Kit, electrophoresis tank, power supply, ready-agarose gel and electrophoresis buffer] necessary for conventional PCR, was developed for the identification of bioterrorism agents in the field. In this study we aimed to evaluate the efficacy of a ready-to-use commercial PCR kit (Nanobiz, Ankara, Turkey) targeting the tul4 gene, for the diagnosis of tularemia and to compare the results with an in-house conventional PCR and a rtPCR test. We applied the assay to a collection of four F.tularensis standard strains, 15 field isolates (from humans, animals, water), 13 non-Francisella strains which are phylogenetically related to F.tularensis and a total of 60 lymph node aspirates obtained from suspected tularemia cases. Compared to the in-house PCR method used in our laboratory, the sensitivity, specificity, positive and negative predictive values of Nanobiz PCR Toolbox assay were found to be 100%. The lowest detection limit of this method was determined as 100 genomic equivalent per PCR reaction mix. The new PCR kit is a rapid and accurate alternative to the conventional PCR methods since the toolbox includes all of the required chemicals, accessories and equipments. This ready-to-use PCR assay was appraised to be a valuable diagnostic tool for the detection of F.tularensis in the outbreak settings particularly in remote areas with limited resources.

Tularemia during pregnancy: report of four cases.

Tularemia during pregnancy is exceedingly rare and has been reported infrequently in Europe. A review of the literature identified only 3 documented cases. Herein we report 4 tularemia cases occurring early in the second and third trimesters, which were successfully managed without any adverse pregnancy outcomes.

[A severe cutaneous anthrax case complicated with sepsis in Bursa, Turkey]. / Bursa'da sepsis klinik tablosu ile seyreden agir deri sarbonu olgusu.

Anthrax is a zoonotic infection caused by Bacillus anthracis. Although the incidence of disease has been decreasing in Turkey, it is still endemic in some regions of the country. The cutaneous form of disease is the most common clinical form, usually benign and rarely causes bacteriemia and sepsis. In this report, a case of cutaneous anthrax complicated with sepsis where B.anthracis was isolated from blood and wound cultures, was presented. A 53-years-old male living in Bursa province (northwestern Turkey), admitted to the emergency ward with high fever and a lesion on the right arm. His history indicated that he is dealing with livestock breeding and injured his arm during slaughtering of a sick lamb. The infection started as a black colored painless ulcer with 2 cm in diameter on his right elbow. The case was hospitalized and penicillin G therapy was started with the preliminary diagnosis of anthrax. Bullous lesions occurred around the wound, got necrosis and integrated with the first lesion. Gram stained slides from the bullous lesions revealed capsulated gram-positive bacilli under light microscope. Gram-positive bacilli were also isolated from bullous lesions and the blood cultures. The isolates were identified and confirmed as B.anthracis by conventional and molecular methods. Antibiotic susceptibility tests were performed by E-test method and the isolates were found to be susceptible to ampicillin, tetracyclin, tigecyclin, ciprofloxacin, levofloxacin, gentamycin, chloramphenicol, erythromycin, clarithromycin, vancomycin, linezolid, daptomycin and rifampicin. The lesion became surrounded by an extensive erythema and edema and expanded to the whole arm. Moxifloxacin was initiated due to the fact that clinical progress. During the second week of the therapy, a black colored scar was observed on the wound while hyperemia and edema regressed. The necrotic tissue debridated to accelerate healing and rest of the skin defect was planned for reconstruction. The patient who had septicaemia and disseminated cellulitis was discharged after his treatment continued for 14 days. Multiple-locus variable-number tandem repeat analysis method was used for molecular epidemiological investigation. The strains isolated from the patient were identified as genotype (GK) 43 classified in A3.a major cluster, and found to be identical to those strains isolated from animals in different provinces located at central and eastern Anatolia of Turkey. In conclusion, the risk of sepsis must be considered in patients with cutaneous anthrax with appropriate follow-up and treatment plan.

[Tularemia: are hunters really a risk group?]. / Tularemi: Avcilar Gerçekten Bir Risk Grubu mu?

The aim of this study was to investigate the tularemia seroprevalence among hunters mainly hunting in districts with emerging tularemia cases in Yozgat province located at the Central Anatolia region of Turkey. A total of 64 serum samples were collected from the subjects (all were male; age range: 18-67 years; mean age: 42.7 years) registered to Hunting and Shooting Clubs in Yozgat province and it's two districts, during January-April 2010 and anamnestic data were obtained using a questionnaire. The presence of Francisella tularensis antibodies in serum samples were screened by microagglutination test (MAT), and the positive samples were also confirmed by a commercial ELISA kit (Serazym, Germany). Four (6.3%) out of 64 were found to be seropositive for tularemia with titers of 1/160 in three cases, and 1/2560 in one case. All of the MAT positive samples yielded positive results with ELISA test and all seropositive cases had negative brucella agglutination result. No tularemia compatible clinical history were determined in two hunters with 1/160 antibody titer. However, one of the cases had defined symptoms consistent with oropharyngeal form. The hunter with 1/2560 antibody titer developed acute oropharyngeal tularemia and treated with 14 days of ciprofloxacin therapy. Evaluation of risk factors in seropositive cases revealed consumption of spring water as a risk factor. In conclusion, our results indicated a considerable exposure of hunters to F.tularensis in Yozgat province and reflected a high prevalence of the pathogen around Yozgat, which coincided with the high notification rate of tularemia in this region.

[Two cases of acute hepatitis associated with Q fever]. / Q Atesi ile Iliskili Iki Akut Hepatit Olgusu.

Q fever which is caused by Coxiella burnetii, is a worldwide zoonosis. Many species of wild and domestic mammals, birds, and arthropods, are reservoirs of C.burnetii in nature, however farm animals are the most frequent sources of human infection. The most frequent way of transmission is by inhalation of contaminated aerosols. The clinical presentation of Q fever is polymorphic and nonspecific. Q fever may present as acute or chronic disease. In acute cases, the most common clinical syndromes are selflimited febrile illness, granulomatous hepatitis, and pneumonia, but it can also be asymptomatic. Fever with hepatitis associated with Q fever has rarely been described in the literature. Herein we report two cases of C.burnetii hepatitis presented with jaundice. In May 2011, two male cases, who inhabited in Malkara village of Tekirdag province (located at Trace region of Turkey), were admitted to the hospital with the complaints of persistent high grade fever, chills and sweats, icterus, disseminated myalgia and headache. Physical examination revealed fever, icterus and the patient appeared to be mildly ill but had no localizing signs of infection. Radiological findings of the patients were in normal limits. Laboratory findings revealed leukocytosis, increased hepatic and cholestatic enzyme levels, and moderate hyperbilirubinemia- mainly direct bilirubin, whereas serum C-reactive protein and erythrocyte sedimentation rate were found normal. Blood and urine cultures of the patients yielded no bacterial growth. Serological markers for acute viral hepatitis, citomegalovirus and Epstein-Barr virus infections, brucellosis, salmonellosis, toxoplasmosis and leptospirosis were found negative. Acute Q fever diagnosis of the cases were based on the positive results obtained by C.burnetii Phase II IgM and IgG ELISA (Vircell SL, Spain) test, and the serological diagnosis were confirmed by Phase I and II immunofluorescence (Vircell SL, Spain) method. Both cases were treated with doxycycline for 14 days and became afebrile within four days. These cases were presented to emphasize that C.burnetii infection should be considered in the differential diagnosis of patients with fever and elevated serum transaminase levels, irrespective of the presence of abdominal pain and exposure to potentially infected animals.

Antimicrobial susceptibilities of Francisella tularensis subsp. holarctica strains isolated from humans in the Central Anatolia region of Turkey.

OBJECTIVES: To assess the in vitro susceptibility of Francisella tularensis subsp. holarctica biovar II strains to 24 antimicrobial agents. METHODS: Thirty-nine F. tularensis strains isolated from humans in the Central Anatolia region of Turkey were examined. Each isolate was identified by conventional and molecular techniques. MICs of aminoglycosides, tetracyclines, fluoroquinolones, macrolides, penicillins, cephalosporins, imipenem, clindamycin, linezolid, chloramphenicol and rifampicin were determined using the Etest method on glucose/cysteine blood agar plates. Interpretation of results was made according to CLSI clinical breakpoints. RESULTS: All strains were susceptible to aminoglycosides, tetracyclines, chloramphenicol, rifampicin and three fluoroquinolones. In contrast, resistance to penicillins, cephalosporins, carbapenems, macrolides and clindamycin was observed for all isolates. Fluoroquinolones had the lowest MIC(50) and MIC(90). CONCLUSIONS: All strains were susceptible to the antibiotics traditionally used to treat tularaemia, such as streptomycin (MIC(90) 1.5 mg/L), gentamicin (MIC(90) 0.25 mg/L), tetracycline (MIC(90) 0.38 mg/L) and chloramphenicol (MIC(90) 0.25 mg/L). Since fluoroquinolones showed the lowest MIC values, and have important advantages over aminoglycosides, including ease of oral administration and lower toxicities, quinolones have the potential for being effective first-line therapy for tularaemia.

[Two cases of tick-borne tularemia in Yozgat province, Turkey]. / Yozgat Ilinde Kene Kaynakli Iki Tularemi Olgusu.

Tularemia which has a worldwide distribution, is a zoonotic infection caused by Francisella tularensis. F.tularensis can infect a wide range of animals and can be transmitted to humans in a variety of ways, the most common being by the bite of an infected arthropod vector (usually tick) in the USA and Europe. The clinical presentations have been classically divided into ulceroglandular, glandular, oculoglandular, pharyngeal, respiratory, and typhoidal tularemia depending on the route of transmission. Arthropod-borne infection generally leads to the ulceroglandular form of tularemia. In Turkey, oropharyngeal form which is related to the consumption of contaminated water, is the most common presentation of tularemia. In this report, two cases of ulceroglandular tularemia which developed as a consequence of tick bite in Yozgat province have been presented. A 33-year-old female patient was admitted to the hospital with a tender lump on the right axilla. Empiric antibiotic treatment with amoxicillin clavulanate did not lead to an improvement in the painful axillary mass. She reported a tick bite on her right shoulder before development of fever, chills and regional tender lump. On physical examination, hyperemia was seen on the shoulder, with enlarged tender right axillary lymph node. The clinical diagnosis of suspected ulceroglandular tularemia was confirmed by the seroconversion (1/160 and 1/1280 titers in acute and convelescent sera, respectively) with microagglutination test (MAT) and F.tularensis DNA positivity in lymph node aspirate by polymerase chain reaction. The agent was identified as F.tularensis subsp. holarctica based on the results of amplification of target RD1 gene. Second case, a 18-year-old male, was admitted to our hospital with a-week history of sudden onset of fever, headache, generalized aches, vomiting, nause, and tender lump on the left axilla. On physical examination, an inflammatory eschar was seen on his scalp with enlarged cervical lymph node on left side. The tick, which has removed from the scalp lesion by the patient himself was identified as Dermacentor spp. The suspected diagnosis of ulceroglandular tularemia was confirmed by 1/2560 titer positivity obtained with MAT. Gentamicin (5 mg/kg/day, PO) was initiated for the treatment of both patients, however, LAP did persist in both of them requiring abscess drainage and prolonged treatment with gentamicin following a 14-day course of ciprofloxacin (1500 mg/day, PO). LAP decreased after medical treatment and repetitive drainage procedures. The patients recovered completely without sequela. These cases, to the best of our knowledge, who were the first confirmed tick-borne tularemia cases in our country, were presented to call attention to a different mode of transmission for F.tularensis.

[An oropharyngeal tularemia case diagnosed by the isolation of Francisella tularensis on human blood agar]. / Francisella tularensis'in insan kanli agarda izole edilmesiyle tanimlanan bir orofarengeal tularemi olgusu.

Tularemia which is a multisystem disease of humans and some animals, is endemic in North America, some parts of Europe and Asia. The causative agent, Francisella tularensis, is a fastidious gram-negative, intracellular bacterium which requires supplementation with sulphydryl compounds (cysteine, cystine, thiosulphate, isoVitaleX) for growth on common laboratory media. In this report, a case of oropharyngeal tularemia diagnosed by the isolation of the causative agent on non-selective-common microbiological agar, has been presented. The patient was from Yozgat located in central Anatolia where tularemia has not been reported so far. Forty-two years old male was admitted to the hospital with two weeks history of sudden onset fever, headache, generalized aches, sore throat, and cervical tender lump on the left. Physical examination revealed bilateral exudative tonsillitis and tender posterior cervical lymphadenopathy. He has been empirically treated with amoxicilin-clavulanic acid for 7 days with initial diagnosis of acute tonsillopharyngitis. However, he was admitted to the hospital since the symptoms persisted and swelling increased despite antibiotic therapy. Microscopical examination of the Gram and Ehrlich-Ziehl-Neelsen stained smears prepared from the surgically drained lymph node revealed PMNL, with no evidence of bacteria. Routine cultures of the lymph node material yielded growth of gram-negative coccobacilli only on human blood agar and the cultures were negative for pyogenic bacteria, acid-fast organisms and fungi. Pathologic examination of the drainage material revealed suppurative inflammation. Lymph node aspirate and serum samples of the patient together with the isolated strain were sent to reference laboratory for further investigation in accordance to the clinical and laboratory findings compatible with tularemia. The isolate was confirmed as F.tularensis by slide agglutination and direct immunofluorescence antibody tests, and identified as F.tularensis subsp. holarctica by polymerase chain reaction. Microagglutination test performed on patient's serum yielded positive with an antibody titer of 1/5120. Gentamicin (5 mg/kg/day) was initiated, and the therapy was completed for two weeks. The patient recovered completely without sequela. This case was presented in order to call attention to the strain of F.tularensis which failed to demonstrate a requirement for cysteine and enriched medium on primary isolation, but grew well on conventional laboratory medium. Tularemia should be considered in the differential diagnosis of related infectious diseases since cases of tularemia have been reported from several parts of Turkey after the year 2004.

The modeling and analysis of transesterification reaction conditions in the selection of optimal biodiesel yield and viscosity.

Among alternative fuels, biodiesel has been emphasized as a substantial candidate for diesel engines because of many advantages. However, the main shortcomings preventing more widespread use of biodiesel are high production cost and viscosity. In order to simultaneously overcome both of these shortcomings, the reaction conditions for the transesterification of waste cooking oil (WCO) were optimized using Taguchi and the full factorial design approaches. The analyses of signal to noise ratio and variance were also performed to identify the dominance of reaction conditions on viscosity and biodiesel yield. As a result, the optimal reaction conditions giving the lowest kinematic viscosity (3.991 cSt) and the highest biodiesel yield (98.19%) were determined to be as follows: sodium methoxide amount of 1.00 wt%, reaction time of 60 min, reaction temperature of 55 °C, and methanol to oil molar ratio of 6:1. The catalyst amount and methanol to oil molar ratio were found to be the most significant conditions influencing on the viscosity (10.36% and 78.87% contributions) and the yield (58.48% and 20.17% contributions), respectively. Finally, all physicochemical properties of final waste cooking oil biodiesel (WCOB) produced under optimal reaction conditions were found to meet the EN 14214.

Procalcitonin Level and Its Predictive Effect on Mortality in Crimean-Congo Hemorrhagic Fever Patients.

Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease which is endemic to Turkey. We aimed to investigate the procalcitonin levels and their prognostic value over fatality in CCHF patients. The sera were harvested from patients who were diagnosed with CCHF within the first 2 days of the onset of their symptoms. The patients were divided into 2 groups according to their survival status: fatal or non-fatal. The biochemical and hematological parameters were studied in the Biochemistry Laboratory of Sorgun City Hospital. The sera were stored at -80℃ until testing for procalcitonin, and the procalcitonin levels were assayed by ELISA at the Biochemistry Laboratory of Kirikkale University. Forty- eight patients were included in the study, with 8 and 40 patients in the fatal and non-fatal groups, respectively. While the procalcitonin level was high in all patients in the fatal group, the same was observed in 30 patients in the non-fatal group (75%). The mean value of procalcitonin was 1.12 ng/ml in the fatal group and was 0.21 ng/ml in the non-fatal group (P = 0.003). According to the results of our study, the procalcitonin levels in the first 2 days of the onset of the symptoms might be helpful for predicting fatality in CCHF patients.

Evaluation of a commercial immunochromatographic assay for the serologic diagnosis of tularemia.

Tularemia is an infection caused by Francisella tularensis with a worldwide distribution in the northern hemisphere and diverse clinical manifestations. Serology plays an important role in the diagnosis of tularemia. A commercially available immunochromatographic assay (ICA) for the serologic diagnosis of tularemia (VIRapid Tularemia, Vircell, Granada, Spain) was evaluated, and the performance was compared with that of the current standard, the microagglutination test (MA). A panel of 221 sera from 109 cases of tularemia was tested as well as 236 sera from normal individuals or individuals with other infectious or autoimmune diseases. The ICA demonstrated 91.5% (κ = 0.91) agreement with the reference method (MA) and gave an overall sensitivity of 99.3% and a specificity of 94.6%. No cross-reactivity was observed in the ICA with serum samples from normal individuals and patients with autoimmune diseases and bacterial, viral, and parasitic infections, although 4 of 50 patients with brucellosis demonstrated positive results in the ICA. The performance of ICA was simple, and it requires no specialized equipment. The ease of use and significantly high sensitivity and specificity of ICA make it a good choice for diagnostic testing and a valuable field test to support a presumptive diagnosis of tularemia in remote areas.

Health-related quality of life and the prevalence of post-traumatic stress disorder among Crimean-Congo hemorrhagic fever survivors.

Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal infectious disease, and it is endemic in Turkey. Patients are placed in isolation when hospitalized, and some may require blood transfusions. Moreover, some patients may require admission to intensive care units (ICU). CCHF is not a recurrent disease, and relapses are not expected. Therefore, no medical follow-up is conducted on recovery from CCHF. In this study, health-related quality of life (HRQL) and the presence of post-traumatic stress disorder (PTSD) among CCHF survivors were evaluated 12 months after recovery from the disease. PTSD diagnosis was established by DSM-IV-TR criteria and HRQL was investigated by using the Medical Outcomes Study Short Form 36. This study included 54 patients. Our results showed that 48.1% of the patients had PTSD symptoms and 18.5% had PTSD. PTSD incidence was higher among patients who required an ICU stay, who had bleeding, and who required blood transfusion. In addition, 4 out of 8 dimensions of HRQL were impaired. However, none of these patients admitted psychiatric problems to health care professionals. Our findings revealed that periodic psychiatric evaluation should be performed on CCHF patients, and they should be provided medical support, if required.