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.

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 Yil 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.

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.

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.

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.

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.

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.

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.

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.

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]. / Olgu Sunumu: Van Ilindeki Plasmodium vivax Sitmasi.

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.

Renal involvement in Brucella infection.

OBJECTIVES: To examine our patients with brucellosis and renal involvement. Although brucellae have been recovered from the urine of patients with brucellosis, renal involvement is uncommon. METHODS: The data from 15 patients (8 males and 7 females, mean age 43 +/- 18.9 years, range 16 to 80), who had been admitted to our hospital with the diagnosis of brucellosis with renal involvement from 1998 to 2006, were retrospectively evaluated. RESULTS: In almost all cases, urinalysis revealed hematuria and variable amounts of proteinuria; some of the patients had pyuria. Of the 15 patients, 14 had renal failure. The etiology of renal failure was prerenal azotemia in 1, acute tubular necrosis because of nonsteroidal anti-inflammatory drug use in 1, anuric tubulointerstitial nephritis due to rifampin use in 1, nephritis accompanied by brucellar endocarditis in 3, brucellar endocarditis and tubulointerstitial nephritis-associated vasculitis in 1, brucellar membranoproliferative glomerulonephritis in 1, and brucellar tubulointerstitial nephritis clinically in 6 patients. Hemodialysis was required in 5 patients. Chronic renal failure developed in 1 patient, 2 patients were lost to follow-up, and renal function completely recovered in 11 patients. Two patients underwent renal biopsy and membranoproliferative glomerulonephritis with intraglomerular infiltration of histiocytes was identified in 1 patient and chronic tubulointerstitial nephritis associated with vasculitis and immune complex nephritis features was identified in the other. CONCLUSIONS: In areas endemic for brucellosis, this infection can be associated with hematuria, proteinuria, and renal failure. In addition, many diverse etiologies can play a role in the renal involvement associated with Brucella infection.

A brucellosis case presenting with mass formation suggestive for tumor in soft tissue.

We report here a 70-year-old female patient who was diagnosed with brucellosis and presented with mass formation resembling a tumor. The mass was protuberant, 10 cm from the skin surface with a diameter of 15 cm, located at the inferior-lateral region of the left scapula. Brucella melitensis was yielded from culture of mass fluid. The patient responded to ceftriaxone, rifampin and doxycycline therapy and recovered without any sequela at the end of surgery and 3 months of medical treatment.

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.