Evaluation of epidemiological, clinical, and laboratory features and mortality of 144 HIV/AIDS cases in Turkey.

Background The number of HIV/AIDS cases in Turkey is increasing rapidly, as is the number of cases worldwide. The aim of this study is to evaluate the characteristics of the clinical and laboratory findings and epidemiological features of HIV/AIDS patients to obtain useful data on the epidemic type and transmission routes associated with Turkey and to identify risk factors for mortality. Methods The patient records of 144 HIV-infected patients who were admitted to our clinic between 2000 and 2015 were analyzed retrospectively. Results Most of the cases (55%) were diagnosed due to the detection of anti-HIV-positive individuals without clinical symptoms. The mean CD4 + lymphocyte count on first admission was 108 cells/µL for those admitted before 2009 and 265 cells/µL for those admitted after 2009 (p = 0.003). When the pre- and post-2009 groups were compared for the status of the disease, 55.6 and 44.4% of patients were in the AIDS stage, respectively (p = 0.04). The most noted opportunistic infection was mycobacterial, and throughout the follow-up, 31.2% of the cases were fatal. Conclusions Early diagnosis of HIV infection can have a direct impact on prognosis and survival. Therefore, screening laboratory investigations should be extended, particularly in high-risk groups.

Analysis of epidemiology and risk factors for mortality in ventilator-associated pneumonia attacks in intensive care unit patients.

BACKGROUND/AIM: The aim of this study was to investigate the epidemiologic characteristics, the causative microorganisms and their antimicrobial susceptibility patterns, and the prognostic risk factors for mortality in critically ill patients with ventilator-associated pneumonia (VAP). MATERIALS AND METHODS: In this retrospective observational study, all the critically ill patients with VAP hospitalized in a medical/surgical intensive care unit (ICU) between January 2010 and June 2015 were evaluated. Patients' demographic features and microbiological data were reviewed. RESULTS: A total of 417 patients were clinically diagnosed with VAP; 51.1% of them were male and the average age was found as 69.9 ± 15.9 years. VAP was detected at approximately 25.0 ± 18.0 days of ICU stay and 17.9 ± 12.6 days after intubation. Acinetobacter baumannii (69.5%) was isolated as the most frequent VAP agent, and the most effective antibiotic was colistin. The crude mortality rate was detected as 39.8% among the patients. The presence of dyspnea at admission, coronary heart disease as a comorbidity, unconsciousness at admission, steroid usage, and prolonged hospital stay were observed as independent risk factors in multivariate analysis (P < 0.01). CONCLUSION: According to the etiological microorganisms and antimicrobial susceptibility patterns, colistin was found to be the most reliable antibiotic for empirical antimicrobial therapy.

Investigating the in vitro synergistic activities of several antibiotic combinationsagainst carbapenem-resistant Acinetobacter baumannii isolates.

BACKGROUND/AIM: Acinetobacter baumannii (A. baumannii) is one of the most common healthcare-associated infectious agents worldwide. The aim of this study was to investigate the in vitro synergistic activities of several antibiotic combinations against carbapenem-resistant (CR) A. baumannii isolates. MATERIALS AND METHODS: Eighteen CR A. baumannii strains were isolated from the patients who were hospitalized in the intensive care unit between June 2012 and August 2012. The in vitro effects of single and binary combinations of meropenem (MEM), colistin (CST), tigecycline (TGC), and sulbactam (SUL) on these isolates were determined using the Epsilometer test (E-test) method. RESULTS: All 18 isolates were resistant to MEM and SUL and susceptible to CST. TGC was detected as susceptible in two of the isolates and intermediate susceptibility results were observed in the remaining isolates. With MEM-CST and MEM-TGC combinations, synergism was determined against all isolates. The synergistic and/or additive effect ratios were detected in MEM-SUL, CST-SUL, TGC-SUL, and CST-TGC combinations as 16.7%, 38.9%, 16.7%, and 5.6%, respectively. CONCLUSION: Among the tested antimicrobial combinations, the in vitro combination of MEM with TGC or CST was most effective against the CR A. baumannii strains.

Does the course of laboratory parameters help us to predict the outcome of CCHF?

BACKGROUND/AIM: This study was performed to identify the characteristics distinguishing fatal and nonfatal cases of patients diagnosed with Crimean-Congo hemorrhagic fever (CCHF). MATERIALS AND METHODS: A total of 92 patients with confirmed diagnosis of CCHF in 2009-2013 were included in the study. RESULTS: A high level of urea and aPTT on the third day of hospital stay, diarrhea, somnolence, and the interval from the beginning of the symptoms to hospital admission were independently associated with fatality. Each 10-unit increase in aPTT and urea levels increased the fatality rate by 3.379-fold and 1.236-fold, respectively. Delay in hospital admission increased the fatality rate 1.453-fold for each day of delay. When comparing first and third admission-day laboratory values, the increase in leukocyte counts and the decrease in CPK, urea, creatinine, aPTT, PT, INR, and hemoglobin levels were significant in nonfatal cases. CONCLUSION: This study showed that the course of these laboratory tests helps us to predict the outcome of the disease. In a few days of hospitalization, persistence or progress of the abnormal laboratory parameters may warn us about poor prognosis.

Multi-center prospective evaluation of discharge criteria for hospitalized patients with Crimean-Congo Hemorrhagic Fever.

INTRODUCTION: The information of discharge criteria in patients with Crimean-Congo Hemorrhagic Fever (CCHF) is limited. In this study, we aimed to determine the clinical and laboratory parameters used in discharging the patients by the experienced centers. MATERIALS AND METHODS: The study was done in 9 reference centers of CCHF from May 1, 2015 to December 1, 2015 and included laboratory-confirmed patients with CCHF. The study was prospective, observational and non-interventional. RESULTS: The study included 260 patients. Mean age was 51.3 ± 16.3 years; 158 (60.8%) were male. Mean hospital stay was 7 ± 2.6 days. The decision of discharging was taken considering clinical and laboratory findings. On discharge, no patients had fever or hemorrhage. The patients were followed-up clinically and a repeat CCHF PCR was not studied. All centers considered the following criteria for discharge: no fever and hemorrhage, improvement in clinical findings and laboratory studies. For all patients except one, platelet count was >50,000/mm(3) and had a tendency to increase. Prothrombin time and international normalized ratio (INR) were normal in 258 (99.6%) and 254 (98.1%) patients respectively. Alanine aminotransferase (ALT) was either normal or not higher than 10-fold and had a tendency to decrease in 259 (99.6%) patients. ALT and aspartate aminotransferase (AST) levels were not taken as discharge criteria with priority. During 30 days following the discharge, complication, relapse, or secondary transmission were not reported. CONCLUSIONS: The discharging practice of the centers based on clinical and laboratory parameters seems safe considering no complications, relapses, or secondary infection thereafter. Current discharge practice of the centers composed of no fever and hemorrhage, improvement in clinical findings, platelet count of either >100,000/mm(3) or >50,000/mm(3) with a tendency to increase, and normal bleeding tests can be used as the criteria of discharge.

A long-term survey of brucellosis: Is there any marker to predict the complicated cases?

BACKGROUND: This study aimed to find markers to predict complicated cases in brucellosis. Patients with and without complications were compared in terms of epidemiological, clinical and laboratory properties. METHODS: A total of 700 patients hospitalised at the Department of Infectious Diseases and Clinical Microbiology were evaluated retrospectively. RESULTS: Of a total of 700 patients, 383 (54.7%) were male and mean age was 41.5 ± 17.0 years. Of the patients, 517 (73.8%) were classified as acute cases. Complications occurred significantly less frequently in acute infections (p < 0.001). Increased C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) occurred more frequently in patients with complicated cases (p = 0.005 and 0.021, respectively), whereas malaise, myalgia and blood culture positivity occurred significantly less frequently in those cases (p < 0.001, < 0.001 and 0.014, respectively). Fever at examination, loss of malaise and myalgia and blood culture negativity were statistically significant predictive factors for complicated patients in multivariate analysis (p < 0.001, for each). As compared to patients without orchitis, leukocytosis occurred more often in cases with orchitis (p < 0.001); leukopenia occurred more often in neurobrucellosis than in cases without neurobrucellosis (p = 0.008). Of patients who attended control regularly, 422 (98%) were treated successfully. All of the nine patients who did not recover fully were cases with osteoarticular involvement. CONCLUSIONS: Fever was the most significant predictive marker of complications. Other classical symptoms of brucellosis like myalgia and malaise were absent in most of the complicated cases. Blood culture was of limited value in the diagnosis of complicated cases most of the time.

Crimean-Congo Hemorrhagic Fever: Prognostic Factors and the Association of Leukocyte Counts with Mortality.

We aimed to determine the relationship between leukocyte counts and the survival of patients with Crimean-Congo hemorrhagic fever (CCHF), a life-threatening illness. This is the first study to do so. A total of 220 patients with CCHF were evaluated retrospectively. The mortality rate was 16.4%. Analysis of the relationship between leukocyte counts and mortality rates provided insight into the pathogenesis of CCHF. Receiving operating curve analysis revealed that leukocyte counts ≥2,950/mm(3) on the day of admission predicted mortality rate with 62.1% sensitivity. The mean hospitalization stay in patients with fatal disease was 4.3 days; therefore, leukocyte counts were compared on the day of admission and day 3 of the hospital stay. Increases in neutrophil levels and decreases in lymphocyte and monocyte levels were identified as significant risk factors for mortality (P = 0.01, 0.037, and 0.001, respectively). The mortality risk was 7-12 fold higher in patients whose levels of leukocytes (2,950 µL), lactate dehydrogenase (967.5 U/L), and alanine aminotransferase (>119.5 U/L) and activated partial thromboplastin time (42.4 s) exceeded the cut-off values; these were identified as independent predictors of mortality. Depletion of monocytes and lymphocytes and accumulation of neutrophils correlated with poor outcome. These results highlight the importance of the mononuclear immune response for the survival of patients with CCHF.

Emergence of multidrug resistant isolates and mortality predictors in patients with solid tumors or hematological malignancies.

INTRODUCTION: Infections are an important preventable cause of death in cancer patients. The aim of this study was to clarify the epidemiologic characteristics and resistance patterns of causative isolates and mortality predictors in infections of cancer patients. METHODOLOGY: Patients with sterile site infections were evaluated in a retrospective cohort study. Etiological agents, antimicrobial resistance patterns of the isolates, and possible risk factors for mortality were recorded. Survivors and non-survivors on day 30 after each infection onset were compared to identify the predictors of mortality. RESULTS: A total of 205 infection episodes of 132 patients were included in this study. Of them, 75% had hematologic malignancies and 25% had solid tumors. Febrile neutropenia was diagnosed in 61.5%. Bloodstream infections were the most frequent infection (78%). The majority of the pathogens were Enterobacteriaceae (44.3%) and nonfermentative isolates (17.6%). Multidrug-resistant (MDR) infections were responsible for 40% of the episodes. The mortality rate was 23.4%. Inadequate initial antibiotic treatment (OR = 4.04, 95% CI = 1.80-9.05, p = 0.001), prolonged neutropenia (> 7 days) before infection (OR = 3.61, 95% CI = 1.48-8.80, p = 0.005), infection due to Klebsiella species (OR = 3.75, 95% CI = 1.31-10.7, p = 0.013), and Acinetobacter baumannii (OR = 5.00, 95% CI = 1.38-18.2, p = 0.014) were independent predictors of mortality. CONCLUSIONS: Gram-negative isolates were found to be the predominant pathogens with higher mortality rates. Local epidemiological data should be taken into account when administering empirical therapy since the inadequacy of initial antibiotherapy is associated with a poor outcome.

A case of Crimean-Congo hemorrhagic fever complicated with acute pancreatitis.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease characterized by nonspecific symptoms like fever, myalgia, severe headache, nausea, vomiting, diarrhea, and abdominal pain. It can result in various complications during the course of the disease due to the diffuse endothelial injury involved in the pathogenesis of CCHF. OBJECTIVES: Here we present a patient with CCHF complicated by acute pancreatitis, including pleural and intra-abdominal effusions. CASE REPORT: A 70-year-old patient was referred to our hospital from an endemic area with the suspicion of CCHF. The physical examination of the patient revealed high fever (38°C), somnolence, and petechial eruption. The diagnosis of case was confirmed with positive reverse transcriptase polymerase chain reaction (RT-PCR). The viral load of the patient was 4×10(9) copies/mL. On the fifth day of admission, upper abdominal pain, scleral ichter, and abdominal distention developed. The patient had abdominal tenderness with guarding. The laboratory tests revealed an amylase level of 1740 U/L (28-100), lipase level of 583 U/L (13-60), and total bilirubin level of 3.75 mg/dL (<0.3). The diagnosis of acute pancreatitis was confirmed with radiological findings. CONCLUSIONS: Until now, atypical presentations of CCHF have been reported in some case reports, but not acute pancreatitis. To the best of our knowledge, this is the first case of acute pancreatitis in the literature seen in the course of CCHF.

Clinical and microbiological efficacy and toxicity of colistin in patients infected with multidrug-resistant gram-negative pathogens.

Polymyxins have recently again become important because of multidrug-resistant (MDR) gram-negative pathogens. The aim of this study was to evaluate the clinical and microbiological efficacy and toxicity of different dosages of colistin in patients infected with MDR microorganisms that were sensitive only to colistin. The study was conducted in the 1,200-bed Ankara Numune Training and Research Hospital. Patients with normal renal function who received colistin for 48 h or more were retrospectively evaluated. Clinical response was defined as resolution of fever and clinical and laboratory findings. Microbiological response was defined as bacteriological eradication from the infection site. Nephrotoxicity was defined as at least two consecutive serum creatinine measurements with an increase of 0.5 mg/dl from baseline at least 24 h apart after 2 or more days of colistin therapy. Twenty-four patients were included in the study: total clinical response was obtained in 17 of 24 (70.8 %) patients and microbiological response in 15 of 24 (62.5 %) patients. Patients were grouped according to colistin dosage of 3 × 1 million units (MU) versus 3 × 2 MU. Clinical response rates were 69.2 % and 72.7 %, respectively (p = 0.65). Microbiological response rate was similar (p = 0.62). Nephrotoxicity was revealed in 1 of 13 patients (7.7 %) for the 3 × 1 MU group and 2 of 11 patients (18.2 %) in the 3 × 2 MU group (p = 0.57). The nephrotoxicity rate was greater with higher dosages of colistin, but the difference was not statistically significant. Renal function of patients receiving higher dosages of colistin should be more closely monitored.

Two cases of acute hepatitis after a serial knife stabbing.

Three persons became victims of a serial knife stabbing in a fight. Three months later, one of the victims presented with acute hepatitis. On the fifth day of his admission to the hospital, another victim of this serial stabbing presented to our clinic with acute hepatitis B infection. The patients told that the first victim stabbed in this fight was their relative and he was a carrier of hepatitis B virus for a long time. They said that the carier of hepatitis B was stabbed first and then, with the same knife, the first and second patients were stabbed, respectively. After 8 months, the index case (first victim) was admitted to our clinic with elevation of liver enzymes. HBsAg and HBeAg were positive. HBV DNA was 2 × 10 (9) copy/mL. Histopathologic examination of liver biopsy showed chronic hepatitis with histologic activity index of 6/18 and grade I fibrosis.

[Evaluation of tularemia cases originated from Central Anatolia, Turkey]. / Orta Anadolu Kaynakli Tularemi Olgularinin Degerlendirilmesi.

Tularemia is an infection caused by Francisella tularensis with a worldwide distribution and diverse clinical manifestations. In recent years, tularemia cases are increasing in Turkey, with a special attention to Marmara, western Blacksea and Central Anatolia regions. The aim of this study was to evaluate tularemia cases admitted to our hospital during an outbreak emerged at Central Anatolia between December 2009 and September 2010, making a point for the disease. A total of 32 patients (17 female, 15 male; age range: 15-80 years, mean age: 41 ± 16 years) with fever, sore throat, cervical mass and failure to respond to beta-lactam antibiotics, were followed up with the preliminary diagnosis of tularemia. The diagnosis was confirmed by specific laboratory tests. Serum samples were obtained from 25 patients and in 17 (68%) of them microagglutination test yielded positive result (≥ 1/160) in their first serum samples. All of the 8 patients who had negative results in their first samples (< 1/160), revealed seroconversion in their second samples. In 10 (91%) of the 11 patients from whom lymph node aspirates were obtained, PCR performed with species specific (tul4) primers yielded positivity and subspecies differentiation done by RD1 primers identified the agent as F.tularensis subspecies holarctica. F.tularensis growth was not detected in the cultures of lymph aspirates and/or throat swabs of the cases (n= 16). All the patients had oropharyngeal tularemia and eight of them also had oculoglandular form. The mean duration of the symptoms were 25.6 ± 17.2 (2-60) days. They had a history of oral intake of contaminated water. Cervical or submandibular lymphadenopathy were detected in all patients. One patient had cervical abscess and the other one had erythema nodosum. Elevated sedimentation rate was found in 26 (81.3%) patients and elevated CRP in 24 (75%) patients. Spontaneous drainage was detected in nine cases during follow-up. Lymph node aspiration was performed in patients when fluctuation was detected. Streptomycin 2 g/day for 10 days was given to 21 patients and doxycycline 2 x 100 mg for 14 days was given to 11 patients. Twelve (37.5%) patients received further antibiotic treatment since they failed to respond to the first therapy. Of the patients, 21 recovered completely and two patients had lymph node excision. No severe complications were observed. The patients who applied to the hospital within 10 days of the initiation of the symptoms were treated successfully, while the others that applied later were not. In conclusion, tularemia which is an endemic disease in Turkey, should be kept in mind in patients with fever, sore throat and lymphadenopathy.

The knocked-out erythrocyte sedimentation rate: periodontal abscess.

INTRODUCTION: The erythrocyte sedimentation rate (ESR) is a common but nonspecific test that is often used as an indicator of active disease. Infection of dental origin may be responsible for a number of cases in unresolved elevated ESR and fever etiology. Dental sepsis is the one of the potential causes of persistent fever that can escape detection. CLINICAL PICTURE: An 18-year-old female patient was admitted to the emergency room with complaints of headache, fever, nausea, and vomiting for the past four days. Erythrocyte sedimentation rate was 110 mm/h. She was started empirically on antibiotic treatment as no etiology was found. Four days later, while searching for the etiology of the fever, the patient experienced an acute pain in association with localizing symptoms in two decayed teeth. Oral examination revealed abscess formation in both teeth. TREATMENT: Teeth were extracted and ESR was decreased to 95 mm/h on the day of the second extraction and to 60, 35, and 10 mm/h taken weekly. OUTCOME: During the follow-up, she was in good health with no fever seen 3 months after treatment and her ESR was 15 mm/h. CONCLUSION: Dental infection should be considered as an unusual but very treatable cause of pyrexia of unknown origin.

Cerebellar abscess and syringomyelia due to isoniazid-resistant Mycobacterium tuberculosis.

A 19-year-old immunocompetent man was admitted to hospital with diplopia, nausea, vomiting and change in mental status. The patient had a history of tuberculous meningitis that was diagnosed at another hospital 6 months before the present admission, and at that time anti-tuberculosis treatment was initiated using a first-line drug combination. A computed tomography (CT) scan of the brain revealed non-communicating hydrocephalus. A ventriculo-peritoneal shunt was inserted surgically. Two months later, the patient was hospitalized again for fever, dysphagia and left hemiparesis. At that time, his cranial CT findings were within normal limits; however, magnetic resonance imaging (MRI) revealed an irregular multilocular peripheral contrast-enhancing lesion in the posterior fossa. The abscess was surgically drained. The presence of acid-fast bacilli in the abscess material was demonstrated by Ziehl-Neelsen staining. Mycobacterium tuberculosis grew on Lowenstein-Jensen culture medium, and the strain was found to be resistant to isoniazid. One month after the operation, the patient became quadriparetic. Cervical MRI revealed a cervico-thoracic syringomyelitic cavity, after which a syringoperitoneal shunt was placed. Treatment with four drugs was continued for 10 months, and then treatment with three drugs for a total period of 18 months. The patient recovered, with residual quadriparesis. Even though very rare, isoniazid-resistant M. tuberculosis may be the causative agent of progressive tuberculosis.

[Investigation of serum IgG subclass distributions and anti-HBs response in healthy adults after hepatitis B vaccination]. / Hepatit B asilamasindan sonra saglikli eriskinlerde serum IgG alt tipleri ve anti-HBbs yanitinin arastirilmasi.

The aim of this study was to evaluate the distribution of serum total IgG (tIgG) subtypes before and after hepatitis B vaccinations in young adults and the relationship between anti-HBs titers and tIgG subtypes. Thirty-eight young adults (29 female, 9 male; age range: 18-20 years) who were the students of Malatya Health Care Profession High School were included in the study. Their anti-HBs and total anti-HBc markers' were negative. The study group were immunized with 20 microg/mL recombinant HBV vaccine intramuscularly (Engerix B) at 0, 1st, and 6th months. The tIgG subtype distributions before vaccination and anti-HBs and tlgG subtype distributions after vaccination were investigated. Serum samples were collected one month after the third dose vaccination, and anti-HBs were found negative (<10 IU/ml) in 8 subjects (21%), low positive (10-100 IU/ml) in 14 subjects (37%), and high positive (>100 IU/ml) in 16 subjects (42%). There was no difference between the response groups in terms of tIgG subtype distributions obtained before vaccination. After vaccination, while there was no increase in the tIgG subtypes in the unresponsive group, increased IgG1 levels were determined in low and high response groups. The IgG1 increment ratio was more evident in high response cases. We concluded that IgG1 subtype titer was the most important indicator for the evaluation of the efficacy of active HBV immunization.

Cervico-mediastinal tuberculous lymphadenitis presenting as prolonged fever of unknown origin.

Prolonged fever of unknown origin (FUO) is a challenging and important medical problem. Tuberculosis is the most frequent cause of FUO, especially in endemic regions, such as developing countries. We present a case of cervico-mediastinal tuberculous lymphadenitis that had been searched and followed up as a prolonged FUO. Especially in endemic areas, tuberculosis should be borne in mind in the differential diagnosis of FUO cases with granulomatous lymphadenitis presenting as prolonged or recurrent fever, even if the cultures and polymerase chain reaction for Mycobacterium tuberculosis are negative.